burns 44 (2018) 1947 –1953

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Effects of obesity on burn resuscitation

Jennifer Rosenthal a, * , Audra Clark b, Stephanie Campbell a,

Melanie McMahon a, Brett Arnoldo b, Steven E. Wolf b, Herb Phelan b
a
Parkland Health & Hospital System, Dallas, TX, USA
b
Department of Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA

article info abstract

Keywords: The effects of obesity on resuscitation after severe burn are not well understood. Formulas to
calculate 24-h resuscitation volumes incorporate body weight, which in obese patients often
Burn
leads to excessive fluid administration and potential complications such as pulmonary
Resuscitation
edema, extremity or abdominal compartment syndrome, and longer mechanical ventilation.
Obesity
We evaluated the impact of obesity on 24-h fluid resuscitation after severe burn using a
Parkland formula
cohort of 145 adults admitted to the burn ICU from January 2014 to March 2017 with >20%
total body surface area burns. Patients were divided into four groups based on body mass
index: normal weight (index of <25), overweight (25–29.9), obese (30–39.9), and morbidly obese
(>40). Median total body surface area burn was 39.4% (interquartile range: 23.5%–49.5%).
Patients were 74.5% male and demographics and injury characteristics were similar across
groups. Resuscitation volumes exceeded the predicted Parkland formula volume in the
normal and overweight groups but were less than predicted in the obese and morbidly obese
categories (p< 0.001). No difference was found in 24-h urine output between groups (p=0.08).
Increasing body mass index was not associated with increased use of renal replacement
therapy. Only total body surface area burned, and age were independent predictors of
hospital mortality (p<0.001). We conclude that using body weight to calculate resuscitation
in obese patients results in a predicted fluid volume that is higher than the volume actually
given, which can lead to over-resuscitation if rates are not titrated regularly to address fluid
responsiveness.
Published by Elsevier Ltd.

1. Introduction
Severe burns are associated with increases in vascular
permeability, which leads to third spacing of fluids into tissue;
this is most pronounced within the first 24–48h after injury [1].
Quality resuscitation can have a significant impact on the
patient’s subsequent management. One of the major deter-
minants for survival of severely burned patients is appropriate
fluid resuscitation during the initial phase of injury [2,3].
Having an unbalanced resuscitation of fluid volumes
immediately after injury during the acute phase can result
in significantly higher mortality and complication rates [4,5].
The introduction of fluid resuscitation protocols in the
1960s and 1970s has helped significantly to reduce mortality
from burns [6]. Baxter devised the “Parkland formula,” which
calculates the amount of fluid to resuscitate a patient [6]. Over
the last few decades, the body mass index (BMI) of patients has
continued to increase in America. BMI, used by the World
Health Organization, is the most frequently employed tool to
categorize obesity: it is calculated as a ratio of weight in

* Corresponding author at: Parkland Hospital, 5200 Harry Hines Blvd., Dallas, Texas 75235, USA.
E-mail address: Jennifer.Rosenthal@phhs.org (J. Rosenthal).
https://doi.org/10.1016/j.burns.2018.06.002
0305-4179/Published by Elsevier Ltd.

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1948
kilograms and height in square meters [6,7]. Since the 1960s,
rates of overweight people in the United States have doubled,
rates of obesity have tripled, and morbid obesity has increased
seven-fold [8].
The aim of this study was to demonstrate if BMI has any
impact on the total fluids given during the first 24h and to
compare that with predicted totals derived from using the
patients’ ideal body weight (IBW) to calculate fluid
resuscitation.
2. Methods
2.1. Study setting
The burn intensive care unit at our burn center is a nine-bed
facility within a large level I trauma center. The burn unit uses
electronic medical records.
For this study, the extent of the patients’ burn injuries were
manually estimated by expert burn care providers by using the
Lund–Browder (L&B) diagram. In addition, a computerized
decision support system was used on 55% of patients to guide
the fluid resuscitation process by providing recommendations
for the infusion of crystalloids (lactated Ringer’s) every hour
after admission to maintain the patient’s urinary output in a
targeted range of 30–50ml/h. The computerized decision
support system involves the use of a tablet computer to
determine fluid needs via a built-in algorithm/regression
model that is based on the last three urine output variables,
last infusion volume, and operational business rules. Prior to
having and using this decision support system, we used the
time-honored Parkland formula with an initial calculation of a
fluid rate with subsequent changes of hourly fluid rates in
increments of 10% in order to maintain a urine output of 0.5cc/
kg total body weight. As this has been our gold standard for a
generation, there is of necessity the small element of
subjectivity that is inherent with all burn resuscitations,
computerized algorithms included.
2.2. Study design
We obtained institutional review board approval for this study
to collect and analyze data from 145 patients admitted
between January 1, 2014, and March 5, 2017. Inclusion criteria
included the presence of burn injury affecting more than 20%
of the TBSA. The TBSA calculation was estimated by using the
L&B chart, and resuscitation fluid included prehospital fluid
until the final 24-h mark from time of burn (TOB). Patients had
to have completed the full 24-h resuscitation and had their
height and weight recorded in the medical record. Exclusion
criteria included children under the age of 15years and those
who did not complete the full 24h of resuscitation.
Fluid calculations included adding up fluids prior to arrival
(EMS and/or prehospital fluids), any fluid given to the patient
(blood, albumin, lactated Ringer’s, normal saline, etc.),
including by mouth fluids that were given within the first
24h past the TOB. Once we calculated a 24-h total, it was then
divided by the patients’ weight in kilograms and then divided
by the patients’ TBSA. This gave a milliliter per kilogram total
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for the 24-h mark. Totals were manually recorded by burn care
personnel at the top of each hour.
The following data were collected: age, sex, TBSA, BMI,
height, weight, TOB, and total fluid given in the 24h. Then the
patients’ IBW was calculated using the Hamwi method and
added to the data collected. With the Hamwi method, females
were given a weight of 100 lbs.+5 lbs. for every inch over 5ft and
males were given 106 lbs.+6 lbs. for every inch over 5ft then
converted into kg.
Statistical analysis was carried out using ANOVA to test for
differences in continuous measures between the groups, and
the chi-square test was used for categorical measures. Posthoc
Tukey adjusted pairwise comparisons were completed for
measures that were significant overall. We used linear
regression to find the relationship between cc’s given per kg
and BMI group, age, gender, and whether there was an
inhalation injury. Logistic regression was used to find the odds
of mortality with the same measures plus TBSA. Multivariate
models were built with all measures that reached the 0.20
significance level on univariate analysis. All analyses were
completed at the two-sided 0.05 significance level using SAS
9.4 (SAS Institute, Cary NC) and a posthoc test. Patients were
broken into four groups based on BMI: normal weight
(BMI<25), overweight (25–30), obese (30–40) and morbidly
obese (>40). Patient- and burn-specific characteristics be-
tween the groups were compared. In addition, the patients
were broken into three groups based on their percent
difference from IBW: <12% away from IBW, 12%–29%, and
30%, and the groups were compared. For all analyses, p<0.05
was considered statistically significant.
3. Results
One hundred forty-five patients with >20% TBSA burn were
included (Fig. 1). Demographics of these patients are shown in
Table 1. Mean age, weight, and BMI were 4716.7years, 88.4
21.7kg, and 29.26.8, respectively. Mean IBW was 69.5
11.0kg. Median TBSA burn was 39.4%19.2% (interquartile
range 23.5%–49.5%). Men made up 74.5% of the patients, and
6.2% of all patients had concurrent inhalation injury. Demo-
graphics and injury characteristics were similar across BMI
groups and more so in the percent away from IBW groups.
Resuscitation volumes exceeded the predicted Parkland
formula volume for the patients overall (Fig. 2).
Fig. 1 – Study groups based on body mass index.
 1949

Table 1 – Patient characteristics. proportion of women in the morbidly obese group compared
to the other BMI groups (Table 2).
n = 145
The patients’ variance from their IBW significantly affected
Mean  SD their Parkland formula values when using actual weight in the
Age (years) 4716.7
formula (Table 3), with patients 30% away from their IBW
Weight (kg) 88.4 21.7
having larger values than other groups. The difference
IBW (kg) 69.5 11.0
BMI 29.2 6.8 between fluid intake and the Parkland values (using actual
TBSA (%) 39.4 19.2 weight) was significantly higher for patients <12% away from
Parkland formula 13,819 7457 their IBW compared to the other groups (p=0.002). Similarly,
IBW predicted 10,956 5732 fluid intake expressed as cc’s per kg was significantly
First 24h total fluid (cc) 14,631 8786 associated with IBW variance, with the <12% IBW difference
First 24h total urine (cc) 1610 1021
group having a higher intake than the other two groups (Fig. 4).
Length of stay (days) 26.2 25.1
cc/kg 173.4112.0
Univariate analysis revealed that higher BMI was associat-
cc/IBW 215.0132.9 ed with less fluid per kg (cc/kg) received in the first 24h
cc/TBSA 374.4152.5 (normal, 238.5 cc/kg139.4; overweight, 156.695.1; obese,
cc/TBSA/kg 4.41.9 150.895.8; morbidly obese, 12655.2; p<0.001; Table 2).
cc/TBSA/IBW 5.52.4 However, no statistical significance was found in 24-h urine
output between groups (p=0.09). Increasing BMI was not
No. of patients (%)
associated with increased use of renal replacement therapy.
BMI group
Normal (<25) 36 (24.8) On multivariate analysis, only TBSA and age were indepen-
Overweight (25–30) 60 (41.4) dent predictors of hospital mortality (p<0.001).
Obese (30–40) 40 (24.8) When looking at what the Parkland formula predicted for
Morbidly obese (>40) 9 (6.2) our BMI groups, we found it predicted about 4l too little for the
Gender normal weight group, 1l too little for the overweight group, 1l
Female 37 (25.5)
too much for the obese group, and 4l too much for the morbidly
Male 108 (74.5)
obese group (Table 4). However, using IBW instead of actual
Inhalation injury
No 136 (93.8) weight in the Parkland formula avoided the overestimation of
Yes 9 (6.2) fluids in the obese and morbidly obese groups, where the IBW
Discharge status predication was 4.3 and 7.3l less, respectively, than actual
Alive 105 (72.4) fluids received (Table 5). Using the regular Parkland formula,
Dead 40 (27.6) obese and morbidly obese patients got significantly less fluid
CRRT
than normal weight patients (p=<0.001), though there was no
No 118 (81.4)
Yes 27 (18.6)
difference when IBW was used in the formula (p=0.20).

Abbreviations: BMI, body mass index; CRRT, continuous renal

replacement therapy; IBW, ideal body weight; SD, standard
deviation; TBSA, total body surface area.
4. Discussion

There is an obesity epidemic going on in the United States. This

Fig. 2 – First 24h fluid totals.
No association was seen between BMI group and TBSA
(p=0.27) or cc’s given per TBSA (p=0.26), but cc’s given per kg
(p=<0.001) and cc’s given per TBSA/kg decreased as the weight
groups increased (p=<0.001; Fig. 3). Gender was significantly
associated with BMI (p=<0.001), with a much higher
epidemic is changing the approach to patient care, and burn
care is no exception. Currently there is little data in regard to
obesity and burn resuscitation. In our retrospective study, we
examined patients’ weight and their 24-h burn resuscitation
needs in addition to their IBW-predicted needs and compared
the two. Our results show that a patient’s weight does impact
burn resuscitation insofar as obese and morbidly obese
patients were associated with lower ml/kg fluid resuscitation
volume given.
Two other studies have examined the question of the
effects of obesity on resuscitation volumes after thermal
injury. Similar to our results, both were notable for finding that
increasing actual body weight was associated with lower
volumes of resuscitation. Rae et al. [10] found in a retrospective
analysis of a Glue Grant sample involving 296 burn patients
with a mean TBSA of 41% that obese patients received volumes
per kg that were lower than those of normal weight patients
while also noting a higher mortality in the morbidly obese
population. These authors also found that the morbidly obese
patients were slower to clear their metabolic alkalosis, raising
the question of whether the degree of resuscitation was in fact
adequate. These results were similar in direction and degree to

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Fig. 3 – Weight groups and fluid totals per cc/total body surface area.

Table 2 – Patient characteristics by body mass index group.

Normal (n=36) Overweight (n=60) Obese (n=40) Morbidly obese (n=9) p
Mean SD
Age (years) 44.0 20.6 48.1  16.7 48.0 12.6 46.8 16.6 0.6736
TBSA (%) 44.5 22.9 36.5  16.2 39.6 20.7 38.1 12.2 0.2670
Parkland formula prediction (cc) 11,942 6361 12,097  5363 16,474 9092 21,003 8797 0.0002b,c,d,e
Parkland formula prediction using IBW (cc) 12,313 6755 10,121  4617 11,196 6370 10,027 4692 0.3105
First 24h total fluid (cc) 15,723 8959 12,981  7505 15,510 10141 17,352 9141 0.2700
First 24h total urine (cc) 1278  792 1779 950 1718 1259 1331 874 0.0850
Length of stay (days) 29.0 25.8 23.8  24.9 25.4 25.8 34.2 22.5 0.5851
cc/kg 238.5 139.4 156.6 95.1 150.8 95.8 126.0 55.2 0.0006a,b,c
cc/IBW 231.1 129.7 190.9 126.9 223.3 140.8 275.4 138.1 0.2117
cc/TBSA 353.5 110.7 362.2 169.7 394.2 152.2 451.6 166.9 0.2584
cc/TBSA/kg 5.4 2.1 4.3 1.9 3.8 1.5 3.3 1.2 0.0008a,b,c
cc/TBSA/IBW 5.2 1.9 5.2 2.4 5.7 2.3 7.3 3.2 0.0706
Total fluid minus Parkland 3781  5584 884  5482 964 6925 3651 5241 0.0008b,c
Total fluid minus Parkland IBW 3411  5319 2860 5903 4313 6947 7325 6971 0.1973

No. of patients (%)

Gender
Female 12 (33.3) 12 (20.0) 7 (17.5) 6 (66.7) 0.0094e,f
Male 24 (66.7) 48 (80.0) 33 (82.5) 3 (33.3)
Inhalation injury
No 34 (94.4) 57 (95.0) 37 (92.5) 8 (88.9) 0.8819
Yes 2 (5.6) 3 (5.0) 3 (7.5) 1 (11.1)
Discharge status
Alive 24 (66.7) 45 (75.0) 31 (77.5) 5 (55.6) 0.4584
Dead 12 (33.3) 15 (25.0) 9 (22.5) 4 (44.4)
CRRT
No 27 (75.0) 54 (90.0) 31 (77.5) 6 (66.7) 0.1332
Yes 9 (25.0) 6 (10.0) 9 (22.5) 3 (33.3)

Abbreviations: BMI, body mass index; CRRT, continuous renal replacement therapy; IBW, ideal body weight; SD, standard deviation; TBSA, total
body surface area.
Superscripts next to p values indicate the pairwise posthoc tests that were significant using Tukey’s p-value adjustment.
a
Normal vs. overweight, Tukey’s p < 0.05.
b
Normal vs. obese, Tukey’s p <0.05.
c
Normal vs. morbidly obese, Tukey’s p < 0.05.
d
Overweight vs. obese, Tukey’s p < 0.05.
e
Overweight vs. morbidly obese, Tukey’s p <0.05.
f
Obese vs. morbidly obese, Tukey’s p < 0.05.

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Table 3 – Patient characteristics by percent difference from ideal body weight.

<12% (n=47) 12%–29.9% (n=43) 30% (n=55) p
Mean  SD
Age (years) 45.1  19.3 43.7 13.8 51.1  15.7 0.0598
TBSA (%) 42.1  21.3 37.4 18.2 38.7  18.2 0.4891
Parkland formula prediction (cc) 12,250  6249 12,476 6370 16,209 8605 0.0096b,c
Parkland formula prediction using IBW (cc) 12,296  6436 10,354 5138 10,281 5431 0.1492
First 24h total fluid (cc) 15,642  8226 11,785 6770 15,991 10164 0.0386c
First 24h total urine (cc) 1529  1011 1821 810 1514  1161 0.2708
Length of stay (days) 29.6  28.1 22.0 21.8 26.5  24.9 0.3622
cc/kg 220.7 129.3 140.1 76.5 159.2 107.9 0.0012a,b
cc/IBW 217.9 119.5 169.1 93.8 248.4 159.1 0.0125c
cc/TBSA 384.0 152.4 323.2 137.2 406.3 156.2 0.0231c
cc/TBSA/kg 5.4 2.3 3.8 1.4 4.0 1.7 0.0001a,b
cc/TBSA/IBW 5.3 2.2 4.6 1.7 6.3 2.6 0.0010c
Total fluid minus Parkland 3391  6015 691 3655 218 7308 0.0020a,b
Total fluid minus Parkland IBW 3345  5720 1431 3731 5711  7400 0.0023c

No. of patients (%)

Gender
Female 9 (19.1) 8 (18.6) 20 (36.4) 0.0643
Male 38 (80.8) 35 (81.4) 35 (63.6)
Inhalation injury
No 44 (93.6) 43 (100) 49 (89.1) 0.0847
Yes 3 (6.4) 0 (0) 6 (10.9)
Discharge status
Alive 33 (70.2) 34 (79.1) 38 (69.1) 0.5037
Dead 14 (29.8) 9 (20.9) 17 (30.9)
CRRT
No 37 (78.7) 39 (90.7) 42 (76.4) 0.1656
Yes 10 (21.3) 4 (9.3) 13 (23.6)

Abbreviations: CRRT, continuous renal replacement therapy; IBW, ideal body weight; SD, standard deviation; TBSA, total body surface area.
Superscripts next to p values indicate the pairwise posthoc tests that were significant using Tukey’s p-value adjustment.
a
<12% vs. 12%–29.9%, Tukey’s p < 0.05.
b
<12% vs. 30%, Tukey’s p <0.05.
c
12%–29.9% vs. 30%, Tukey’s p < 0.05.

Liu’s retrospective study of 161 patients with a cohort mean
TBSA of 42%. Liu’s study also found that obese patients had
lower actual resuscitation volumes than predicted while
suffering from a significantly higher risk of mortality [11].
Our results in the present study are consistent with the
findings of lower resuscitation volumes. Additionally, while
our cohort was underpowered with only 9 morbidly obese
patients, the 4 deaths in this subgroup gave it the highest risk
of death of any subgroup.
The etiology for this impact of obesity on resuscitation
volume and outcome is not clear, but several possibilities exist.
The first has to do with the influence of resuscitation protocols
themselves and their efficacy in the obese patient. The three
studies discussed here had mixed approaches to resuscitation.
The Rae study used a traditional Parkland formula for
resuscitation of 4ml/TBSA/kg with titrations based on a urine
output of 10% [10]. Its fidelity to this protocol was high, making
deviations from it less likely as an etiology. The Liu study,
however, used a computerized decision support instrument
with algorithms that dictated changes in fluid administration
rates for the entire cohort [11]. In the present study, we utilized
a mixed approach. The study time period encompassed a move
at our burn unit from using a traditional Parkland formula for
resuscitation to a computerized algorithm. Consequently, 55%
of our cohort was resuscitated with a decision support tool.
Therefore, given that the signals of lower resuscitation and
higher mortality for obese patients persisted across all three
studies, resuscitation protocols are less likely as an etiology.
A second possibility is that the different body surface areas
(BSAs) of morbidly obese and non-obese burn patients make
the calculation of the true BSA burned problematic. The
thought is that with increases in BMI, we may be incorrectly
calculating TBSA burn. The Livingston study showed that with
increases in BMI, an underestimation of the patient’s trunk
and leg BSA was noted [13]. This study was similar in its results
to the Neuman study of 163 patients: an underestimation of
the trunk and leg BSA and overestimation of the arms and head
area with increases in BMI [12,13].
Another possibility is that the unique metabolic
makeup of the morbidly obese patient may have an
interaction with response to thermal injury. These differ-
ences may include a systematic decrease in resuscitation
volume and potential differences in drug absorption with
pharmacokinetic aspects being distributed and excreted
differently [14]. Renal elimination in the obese population
has been found to be increased due to a greater kidney

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1952

mass difference [15]. In addition, there is an association

between obesity and glucose homeostasis abnormalities
as part of the hypercatabolic state in burns, with early
glycemic control moving to the forefront in burn care. In
Murphy’s study, for example, glycemic control early on
was helpful in decreasing overall mortality in burn
patients [16–18].
Final possibility looking at obese patients and how they can
be challenging as adipose tissue has decreased vascularity,
and yet this weight is included in resuscitation formula. A 2018
study by Purvis et al. has data suggesting now that Fresh
Frozen Plasma (FFP) restores glycocalyx integrity and reverses
capillary leak in a shock state. This study compares an
adjusted IBW index formula with FFP rescue to historical
controls resuscitated with Parkland-based resuscitation [19].

5. Conclusion

The use of actual body weight to derive an initial fluid volume

Fig. 4 – Percent difference from ideal body weight.
may result in over-resuscitation of obese and morbidly obese
patients. Using a computerized decision support system and
the patients’ IBW in the Parkland formula for obese and
morbidly obese groups may be a more reasonable starting
point. The results of this study reiterate that weight and TBSA
help in estimating fluid resuscitation. From there, fluid rates
should be titrated to the patients’ needs and responsiveness
[20]. The goal should be to avoid over-resuscitation and the
complications that come along with it, such as edema,
compartment syndrome, and longer days of mechanical
ventilation. Further studies are needed to explain what part
fat plays in burn resuscitation.

Table 4 – Difference between fluids received and predictions by Parkland formula using actual body weight.

Normal (n=36) Overweight (n=60) Obese (n=40) Morbidly obese (n=9) p

Mean SD
First 24h total fluid (cc) 15,723 8959 12,981 7505 15,510 10141 17,352  9141 0.2700
Parkland formula 11,942 6361 12,097 5363 16,474 9092 21,003  8797 0.0002
Total fluid minus Parkland (D) 3781 5584 884 5482 964 6925 3651  5241 0.0008
Less than predicted Less than predicted

“Total fluid minus Parkland (D)” indicates the difference between what patients actually received (total fluid) and what the Parkland formula
estimated for them based on actual weight. Positive numbers indicate that the patients got more fluid than estimated, and negative numbers
indicate that patients got less fluid than estimated.
Abbreviation: SD, standard deviation.

Table 5 – Difference between fluids received and predictions by Parkland formula using ideal body weight.
Normal (n=36) Overweight (n=60) Obese (n=40) Morbidly obese (n=9) p
First 24h total fluid (cc) 15,723 8959 12,981 7505 15,510 10141 17,352 9141 0.2700
Parkland formula using IBW 12,313 6755 10,121 4617 11,196 6370 10,027 4692 0.3105
Total fluid minus Parkland IBW (D) 3411  5319 2860 5903 4313  6947 7325 6971 0.1973

“Total fluid minus Parkland IBW (D)” indicates the difference between what patients actually received (total fluid) and what the Parkland
formula estimated for them based on ideal weight. Positive numbers indicate that the patients got more fluid than estimated, and negative
numbers indicate that patients got less fluid than estimated.
Abbreviation: IBW, ideal body weight.

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Funding
This research did not receive any specific grant from funding
agencies in the public, commercial, or not-for-profit sectors.
Conflicts of interest
None.
Acknowledgment
The authors would like to thank Dave Primm for help in editing
this article.
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