Eur J Anaesthesiol 2013; 30:483–491

ORIGINAL ARTICLE

Comparison of three techniques for calculation of the

Parkland formula to aid fluid resuscitation in paediatric
burns
Owen Bodger, Abrie Theron and David Williams

CONTEXT Inadequate fluid resuscitation of acute burns may
result in hypovolaemic shock. Excessive fluid resuscitation
may result in fluid overload. A nomogram which uses the
popular Parkland formula and ‘4–2–1’ regime has been
recently described to facilitate the calculation of fluid require-
ments in children during the first 24 h following burn injury.
OBJECTIVE To compare the accuracy and speed of calcu-
lation of three different methods (pen and paper, electronic
calculator and nomogram), which all use the Parkland
formula and ‘4–2–1’ regime to calculate maintenance and
resuscitation fluid requirements for children in the first 24 h
after burn injury.
DESIGN A randomised volunteer study using computer-
generated simulated patient data.
SETTING Welsh Centre for Burns, ABM University Local
Health Board, Swansea, UK. Data were collected between
February 2011 and October 2011.
PARTICIPANTS The group consisted of 36 volunteers
including trainee and consultant surgeons and anaesthetists.
INTERVENTION Thirty-six participants performed 318 cal-
culations, using each of the three methods of calculation up
to three times.
MAIN OUTCOME MEASURES Accuracy, speed and
acceptability of the different methods.
RESULTS For nomogram, calculator and pen and paper:
magnitude of error [low (
25%), medium (
50%) and high
(
75%)]: [5.7, 4.7 and 3.8%], [12.1, 12.1 and 7.5%], [28.6,
21.9 and 16.2%]; [P <0.001, P ¼ 0.001 and P ¼ 0.006].
Calculation time: [s; mean (SD)]: 121 (48), 109 (52) and 240
(140); P <0.001. The mean (SD) of the difficulty scores were
17.3 (13), 20.6 (13.4) and 62.2 (23.4); P <0.001.
CONCLUSION The nomogram was the most accurate
method of calculating fluid requirements using the Parkland
formula, was only slightly slower than the electronic calcu-
lator and was deemed the easiest to use. The nomogram is
also low cost, robust, and provides a rapid means of detect-
ing and preventing the large errors that we have shown can
occur when an electronic device is used as the primary
method of resuscitation fluid calculation. We, therefore,
suggest that the nomogram is a suitable method for the
calculation of the Parkland formula to guide resuscitation and
maintenance fluid requirements in the first 24 h of paediatric
burns or for cross-checking the results obtained by other
means of calculation.
Published online 29 May 2013

Background
Inadequate fluid resuscitation of acute burns may result
in hypovolaemic shock and inadequate perfusion of vital
organs resulting in single or multiorgan failure and
systemic inflammatory response syndrome (SIRS).1,2
Excessive fluid resuscitation may cause pulmonary
and cerebral oedema, myocardial infarction and abdomi-
nal compartment syndrome,1,3–7 as well as burn depth
conversion with increased requirement for escharo-
tomies, fasciotomies and grafts.1,6,8,9
The patient’s clinical response is the best guide to fluid
resuscitation therapy. Fluid administration should be
titrated to clinical signs of adequate organ perfusion as
inferred from a urine output of 1 to 1.5 ml kg1 h1 and

From the School of Medicine, Swansea University, Swansea (OB), Department of Anaesthetics, Cardiff & Vale University Local Health Board, Cardiff (AT), Welsh Centre for
Burns, ABM University Local Health Board, Swansea, UK (DW)
Correspondence to Dr Abrie Theron, Department of Anaesthetics, Cardiff & Vale University Local Health Board, Cardiff CF14 4XW, UK
Tel: +44 0 779 312 4900; e-mail: drabrietheron@yahoo.co.uk

0265-0215 ß 2013 Copyright European Society of Anaesthesiology DOI:10.1097/EJA.0b013e328361a58c

Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited.

 484 Bodger et al.
mean arterial blood pressure (MAP).10,11 The Parkland
formula provides a clinically validated algorithm to guide
initial intravenous (i.v.) fluid resuscitation, and has been
widely adopted as a standard for fluid management in the
first 24 h by most referring centres.12–14
The original Parkland formula was designed for resusci-
tation of adult burns, and was based on total volume of
resuscitation fluid to be infused (VTBI) over 24 h of 3 to
4 ml per kg body weight (BWt) per percentage total body
surface area burned (%BSA). This has been modified for
paediatric use by decreasing the volume of resuscitation
fluid to 3 ml kg1%BSA1, and by the addition of main-
tenance fluids based on BWt according to the ‘4–2–1’
regime, wherein 4 ml kg1 h1 is infused for the first 10 kg
BWt, 2 ml kg1 h1 for the next 10 kg (11 to 20 kg) and
then 1 ml kg1 h1 for every kilogram above 20 kg.10,11,15
Nomograms are graphical embodiments of mathematical
relationships, and can be used to rapidly solve specific
mathematical equations.16 Prior to the introduction of
electronic calculators and computers, nomograms were
widely used in engineering and in medicine, wherein
they were used to calculate physiological parameters and
guide treatment.17,18 In the field of burn management,
nomograms have been used to estimate carbon monoxide
exposure.19 Williams has used standard mathematical
techniques to design a nomogram which represents
the Parkland formula and ‘4–2–1’ regime in graphic
form as an aid to the calculation of fluid requirements
in children during the first 24 h following burn injury
(Fig. 1).20–23
All methods of calculation have inherent advantages
and disadvantages regarding ease of use and speed and
accuracy of calculation. Our study compares the accuracy,
speed and difficulty of use of three different methods
(pen and paper, calculator, nomogram) for the calculation
of i.v. fluid requirements using the paediatric Parkland
formula.
Method
We used an anonymised randomised non-clinical
volunteer design for our study. Formal ethical review
was, therefore, not deemed necessary, and appropriate
letters of exemption were issued by our NHS Trust’s
Research Ethics Committee and Research and Develop-
ment office.
If each participant performed too few calculations, the
data would not be representative, but too many calcu-
lations could result in declining performance due to
fatigue. A total of nine calculations per participant (i.e.
three calculations using each method) over a 30-min to
40-min period was, therefore, deemed to be an acceptable
compromise. Power analysis was informed by a previous
study which we had performed to validate the Parkland
formula nomogram for the calculation of resuscitation
Eur J Anaesthesiol 2013; 30:483–491
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fluid requirements in adult burns.24 With an a value of
0.05 and a b value of 0.9, it was estimated that a sample
size of at least 28 participants (performing nine calcu-
lations, using each method three times) would be
sufficient to identify significant differences between
the three groups. The null hypothesis was that there is
no difference in accuracy or speed of calculation when
comparing the three methods.
The participant group consisted of 36 volunteers and
included trainee and consultant surgeons and anaesthe-
tists. Individuals who did not wish to participate for any
reason were not included in the study. The setting was a
quiet room in the hospital, free from interruption or
distractions. The purpose of the study was explained
to the participants. Each received an information sheet
and was given the opportunity to ask further questions or
decline to participate if they wished. Those who elected
to participate signed a consent form, were assigned a
sequential study number and were asked to complete an
anonymised demographic data collection form which
recorded their age, sex, job title and amount of prior
experience in managing fluid resuscitation for paediatric
burns.
All participants received instruction on how to use the
‘4–2–1’ regime and Parkland formula, how to calculate
the VTBI per period and the appropriate rate of admin-
istration of resuscitation fluids per period using each of
the three methods.
Participants had the opportunity to practise each method
and did not proceed until they felt confident to perform
the calculations with each method. During the period of
instruction, it was emphasised that the time of the first
(8 h) period of resuscitation commenced from the time of
the burn injury, not from the time of arrival at the
receiving hospital and participants were shown how to
adjust the calculations to compensate for this. Partici-
pants were instructed to perform the calculations as
quickly as possible to a level of ‘clinically acceptable’
accuracy. It was emphasised, however, that accuracy was
more important than speed of calculation. During the
study, participants were allowed to refer to printed copies
of the ‘4–2–1’ regime, the Parkland formula and the
instructions for the use of the nomogram.
When they were ready to begin, each participant
performed a series of calculations based on computer-
generated simulated clinical scenarios. For each scenario,
participants were given values for BWt (kg), %BSA (%)
and delay (time in hours from burn injury to commence-
ment of resuscitation) from which they calculated three
infusion rates (maintenance, first, and second periods).
They then entered their answers directly into the com-
puter. Participants were allowed to rest between
scenarios if necessary without incurring a time penalty,
and continued until all calculations for the nine scenarios
had been performed. Participants were supervised
 Nomogram to aid fluid resuscitation in paediatric burns 485
The improved Parkland formula and ‘4–2–1’ regime nomogram for paediatric burns.22,23
Fig. 1
Eur J Anaesthesiol 2013; 30:483–491
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 486 Bodger et al.
throughout the process, and were allowed to withdraw at
any point if they wished.
After completing the scenarios, participants were asked
to complete a questionnaire to rate their experience of
each of the three techniques by marking a cross at the
appropriate point on a visual analogue scale (VAS), which
ranged from ‘very easy’ to ‘very difficult’. There was also
an optional section for free text entry of written com-
ments. Data from the VAS were converted to continuous
numerical data by measuring the distance (mm) from the
left hand side of the line (easiest, 0 mm) to the position of
the cross marked by the participant, expressed as a
proportion of the total length of the line (most difficult,
100 mm). Details from the pre- and post-test question-
naires were transcribed onto a spreadsheet for sub-
sequent analysis.
Bespoke software was developed for this study using
‘Python’, an open-source cross-platform object-oriented
programming language, particularly suited to scientific
applications.25 The order in which the three methods of
calculation (pen and paper, calculator or nomogram) was
to be used in each case was determined by the software.
This used a randomisation algorithm, which was analo-
gous to shuffling a deck of nine cards which contained
three cards corresponding to each of the three methods of
calculation to be used, then dealing each of the cards in
sequence without replacement. Hence, each participant
would use each of the three methods of calculation
exactly three times; but the sequence in which each
method was to be used was randomised for each partici-
pant, in order to eliminate any potential bias due to
learning or fatigue effects.
For each simulated scenario, the software randomly
generated and presented the participant with a new set
of simulated clinical data with integer values within
appropriate clinical ranges for BWt (4 to 40 kg), %BSA
(10 to 100%) and delay (1 to 8 h). For each simulated
scenario, the software logged the simulated clinical data,
method of calculation used, participants’ responses and
response time to a spreadsheet (Microsoft Excel, Micro-
soft Corporation, Redmond, WA, USA). The software
also calculated the correct responses to each simulated
clinical scenario using the simulated clinical data and
Parkland formula as described, and logged these to the
spreadsheet.
At all times during the study, both participants and
investigators were blinded to the time taken and correct
Table 1 Common sources of potential error associated with the Parkland formula
Variable
Estimation of body weight
Estimation of total burn surface area
Variation in volume to be infused (VTBI) depending on which version of Parkland formula is used:
VTBI U 4 ml kgS1%BSAS1 or VTBI U 3 ml kgS1%BSAS1
Estimation of the time elapsed between the time of burn injury and the start of fluid resuscitation
Eur J Anaesthesiol 2013; 30:483–491
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answers to each simulated clinical scenario. From sub-
sequent analysis of the resulting spreadsheet, we could
then compare the response time, and frequency and
magnitude of errors in the participants’ application of
the Parkland formula for each simulated scenario and
each method of calculation.
Analysis
Statistical Package for the Social Sciences software, ver-
sion 13 (SPSS Inc., Chicago, IL, USA) was used to analyse
the data.
By the nature of its construction, the nomogram is an
approximate method of calculation compared to the
calculator and so it was anticipated that the calculator
method was potentially capable of greater accuracy than
the nomogram. The design of the nomogram, however,
constrains both the input variables and output to a
clinically relevant range of values and it is, therefore,
incapable of producing the unbounded errors that some-
times arise from careless use of the calculator. Some-
where between these two extremes is the range of most
consequence, wherein errors become large enough to be
clinically significant while not so large as to be obvious.
The Parkland formula requires several measurements to
be inputted, each of which must be estimated. The
expected errors for each of these variables are not trivial,
and are shown in Table 1 below,26,27 with references
wherever available. Combining these using the sum of
squared fractional errors26 gives an expected error in the
final answer of 28%. Given that this is the size of error that
is likely to occur irrespective of the quality of the calcu-
lation, then it must represent the lower end of clinical
significance. We, therefore, defined three thresholds of
error: 25, 50 and 75%, representing categories of low,
medium and high clinical significance as a proportion of
the correct answer.
The accuracy of each method was calculated across all
three thresholds using a non-parametric test (x2 test).
The data for response times were skewed, but a log
transform of these data was accepted by the
Kolmogorov–Smirnov goodness of fit test (P ¼ 0.135)
and, therefore, a parametric test (t-test) was appropriate.
The VAS scores comprised too small a sample (only 36
unique cases) to allow reliable assessment of distribution
and so non-parametric methods were used for analysis.
The free text comments were analysed using an iterative
constant comparison (‘grounded’) approach to allow
Potential error (R/S)
10%
20%26,27
14% (i.e. 3.5 þ/0.5 ml h1 ¼ 0.5/3.5 ¼ 14%)
10%
 Nomogram to aid fluid resuscitation in paediatric burns 487

identification and classification of emerging themes.28–30 Table 2 Accuracy results for small (25%), medium (50%) and large
(75%) errors
Comments that illustrated a particular point of view
or were representative of common themes were quoted Comparison 25% error 50% error 75% error

verbatim in anonymised form. Nomogram vs. calculator 0.097 0.051 0.241

Nomogram vs. pen and paper <0.001 <0.001 0.003
Calculator vs. pen and paper 0.003 0.059 0.049
Results Overall <0.001 0.001 0.006

Around 85% of all calculations were free from an error

(defined as a deviation from the correct score of at least
0.006 for 25, 50 and 75% error thresholds (Table 2). The
25%). Errors occurred during calculation of both the rate
nomogram was considerably more accurate than the pen
for the first and the second period for all methods;
and paper, but although the nomogram was more accurate
however, significantly fewer errors were made calculating
than the calculator, this was only close to statistically
the rate of maintenance fluid (P <0.001).
significance for medium (
50%) errors.
The best performing technique at each level was the
The calculator was the fastest method, followed by the
nomogram, making errors of low significance (
25%),
nomogram and then pen and paper, with mean times
medium significance (
50%) and high significance
(SD) of 109 (52), 121 (48) and 240 (140) s, respectively
(
75%), respectively, only 5.7, 4.7 and 3.8% of the time,
(P <0.001; Fig. 3). There was considerable overlap
compared to 12.1, 12.1 and 7.5% for the calculator, and
between the response times for the nomogram and cal-
28.6, 21.9 and 16.2% for the pen and paper technique
culator, but overall the calculator was slightly faster than
(Fig. 2).
the nomogram (P ¼ 0.013). All three methods showed
A comparison of the frequency of occurrence of errors evidence of improvement of response time with repeti-
with the three different methods was conducted using tion, suggesting a learning effect. This was strongest
the x2 test. Overall, there were significant differences for the nomogram, reflecting its novelty (r ¼ 0.434,
between the accuracy of the three methods for all P <0.001) followed by the calculator (r ¼ 0.341,
thresholds, with P values of less than 0.001, 0.001 and P <0.001) and the pen and paper (r ¼ 0.253, P <0.010).

Fig. 2

Example: Parkland formula nomogram for resus Parkland formula nomogram for resus
A 17 kg child with 55% burns is admitted 4 h after
injury. They have recieved 1000 ml of resuscitation
fluid prior to admission.

From the nomogram:

The infusion rate of maintenance fluid

(given as dextrose-saline) is:
54 ml/h for the first 24 h from the time of burn.

The corrected infusion rates of resuscitation fluid

(given as Hartmann’s solution) are:
100 ml/h for the remaining 4 h in the First Period,
followed by:
Read the infusion rate for maintenance fluid Read VTBI per period from BWt and TBSA ( = 1400 ml).
88 ml/h for the subsequent 16 h in the Second
(dextrose-saline) from the MAINT scale directly adjacent to
Period Bwt ( = 54 ml/h).

arkland formula nomogram for resuscitation of paediatric burns arkland formula nomogram for resuscitation of paediatric burns arkland formula nomogram for resuscitation of paediatric burns

Read infusion rate resuscitation fluid (Hartmann’s) for
First Period (8 h from time of burn) from VTBI and time
remaining in First Period (8 – 4 = 4 h) ( = 350 ml/h).
Read infusion rate resuscitation fluid (Hartmann’s) for
subsequent Second Period (16 h) from VTBI and the 16 h
mark ( = 88 ml/h).
If additional fluid has been given in First Period prior
to admission, subtract this volume from VTBI in step 2
above (1400 – 1000 = 400 ml); re-align VTBI with time
remaining, and read corrected infusion rate ( = 100 ml/h).
VTBI for Second Period remains unchanged.

Example of how to use the Parkland formula and ‘4–2–1’ regime nomogram for paediatric burns.

Eur J Anaesthesiol 2013; 30:483–491

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 488 Bodger et al.

Fig. 3 When we examined the VAS scores for ease of use, we

Method used: Small error (25%+) crosstabulation
found that participants found the nomogram the easiest
method to use, followed by the calculator and then pen
Count
and paper, with mean (SD) difficulty scores of 17.3 (13.0),
Small error (25%+)
20.6 (13.4) and 62.2 (23.4) mm (P <0.001). The user
No Yes Total
rating for the calculator did not affect the size of error
Method used: Calculator 94 13 107
Nomogram 100 6 106
(P ¼ 0.760), error propensity (P ¼ 0.722) or response time
Pen and paper 75 30 105 (P ¼ 0.223). The difficulty score for nomogram was posi-
Total 269 49 318 tively related to higher response times (P ¼ 0.011) but not
Chi-Square tests
to larger (P ¼ 0.478) or more frequent errors (P ¼ 0.472).
For pen and paper, a higher difficulty score was linked to
Asymp. sig. (2-
Value df sided) both a longer response time (P ¼ 0.041) and more fre-
quent errors (P ¼ 0.036), but not to a significantly larger
Pearson Chi-Square 22.557a 2 0.000
Likelihood ratio 22.404 2 0.000 mean error (P ¼ 0.129).
Linear-by-linear
Association 10.808 1 0.001 Univariate statistical analyses showed no significant
N of valid cases 318 correlation between any of the demographic variables
a. 0 cells (.0%) have expected count less than 5. The minimum studied and any of the outcome measures (accuracy,
expected count is 16.18. speed and user preference).
Method used: Medium error (50%+) crosstabulation
Thirty of the 36 participants submitted free text
Count
responses, with each response containing one or
Medium error (50%+)
two discrete items. Qualitative analysis identified
No Yes Total
four main themes (in bold), with the number of
Method used: Calculator 94 13 107
Nomogram 101 5 106
responses in parentheses and representative comments
Pen and paper 82 23 105 as quoted.
Total 277 41 318
Usability (27): The majority of respondents (23) made
Chi-Square tests
positive comments regarding the usability of the nomo-
Asymp. sig. (2- gram (‘very easy to use’). Of these, many (11) also noted a
Value df sided)
significant learning effect over the short period of the
Pearson Chi-Square 13.955a 2 0.000 study (‘becomes easier with practice’). One participant
Likelihood ratio 14.591 2 0.001
Linear-by-linear made the neutral comment that the nomogram was ‘useful,
4.406 1 0.036
Association but does not add a great deal to existing methods’. There
N of valid cases 318 were no negative comments. Compared to the calculator,
a. 0 cells (.0%) have expected count less than 5. The minimum three users deemed the nomogram ‘easier to use’, whereas
expected count is 13.54. one felt ‘the calculator is still easier’.
Method used: Large error (75%+) crosstabulation
Count Speed of calculation (3): Three users commented that the
Large error (75%+) nomogram was ‘much quicker than either other method’.
No Yes Total
There were no negative or neutral comments in this
domain.
Method used: Calculator 99 8 107
Nomogram 102 4 106 Perceived accuracy (4): Two users commented that
Pen and paper 88 17 105
Total 289 29 318 they felt that they were less likely to make errors using
the nomogram compared to the other methods, and
Chi-Square tests
would also use the nomogram to check calculations
Asymp. sig. (2- performed by conventional methods.
Value df sided)
Pearson Chi-Square 10.338a 2 0.006 One user expressed ‘slight concern over accuracy of
Likelihood ratio 10.231 2 0.006
Linear-by-linear reading between the scale markings’. We appreciate
Association 4.784 1 0.029 the concerns of users who are unfamiliar with interpolat-
N of valid cases 318 ing values on logarithmic scales; however, the effect of
a. 0 cells (.0%) have expected count less than 5. The minimum such errors on the fluid rate calculations is extremely
expected count is 9.58. small in comparison to other sources of error (e.g. esti-
mation of %BSA, BWt, time of injury) and is not clinically
Chi-square test results for the comparison of accuracy of three
methods for the calculation of the Parkland formula and ‘4–2–1’ significant. Furthermore, the graduations of the logarith-
regime in paediatric burns. mic scales are more widely spaced towards the lower
end of the scales and, hence, provide increased accuracy

Eur J Anaesthesiol 2013; 30:483–491

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for the more clinically significant values at the lower end
of the data range.
Suggestions for improvements (5): Three participants
stated that usability would be improved and mistakes
would be less likely to occur if users were allowed to
draw lines directly onto the chart rather than lay an
isopleth across the scales. We agree, and recommend
that the nomogram is printed onto sheets of A4 paper
with a Paediatric Lund and Browder chart31 on the
reverse. Both may be written on by the user, and filed
in the notes so that they provide an aid to calculation
as well as part of the medical records. Two users
expressed a need for simpler step-by-step instructions,
and we have, therefore, augmented the verbal and
written instructions with a visual step-by-step guide
(Fig. 2).
Discussion
All 36 participants performed nine calculations, except
for one who chose to withdraw after three calculations.
These data were included because one calculation of
each method was performed.
The software developed for this study worked efficiently
with no problems. The techniques were presented to
each participant in random sequence to eliminate poten-
tial effects of learning or fatigue. The use of automated
timing eliminated potential observer error, and both
participants and investigators were blinded to the correct
results of the calculations and response time to prevent
bias.
The nomogram was more accurate than the calculator
for all classes of error. The pen and paper method
performed worst, with large errors occurring more than
16% of the time. Even without restricting our consider-
ation of errors to those within the range of possible
clinical significance, it was clear that the nomogram had
the highest level of accuracy. The more serious the
errors become, the better the nomogram performed
compared to the calculator.
The response time using the nomogram was nearly twice
as fast as that achieved using a pen and paper and the
nomogram required an additional investment of only
around 12 s compared to the electronic calculator. There
appeared to be a learning effect, which suggests that
response time may be reduced further after an amount
of practice.
The VAS scores showed that the majority of participants
had a preference for the nomogram and considered the
nomogram to be easier to use than the calculator,
although this difference was not significant. This may
reflect the relatively small number of participants in our
study, and differences in the way in which participants
process data, with some being more comfortable with
Eur J Anaesthesiol 2013; 30:483–491
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Nomogram to aid fluid resuscitation in paediatric burns 489
information presented in a graphical format, whereas
others prefer numeric representation.
Various systems have been designed to aid the calculation
of resuscitation fluid requirements based on the Parkland
formula, including dedicated electronic devices;32 com-
puter software;33,34 tables; and mechanical calcula-
tors.15,23,35–41 Compared to the above, nomograms are
low cost, durable (if printed on plastic slates or waterproof
paper), maintenance free, and have no moving parts.
Resuscitation fluid requirements are calculated from the
time of burn, not from the time of arrival in hospital,
which may be several hours later. The rate of infusion
must, therefore, be adjusted to compensate for this, as
well as for any prehospital resuscitation fluids which may
have been given. Many of the systems described above
do not take these factors into account and are, therefore,
difficult to use in practice. The nomogram, however, can
readily perform these calculations (Fig. 4).
Tables may be difficult to read and the discrete values
can introduce rounding errors. Nomograms are easy to
read and provide continuous values across the entire
range, which limits rounding errors.
Electronic devices are not always available, and require a
suitable power source. Inadvertent key presses occur
around 4% of the time during data entry with electronic
devices and this is compounded by the adoption of
different standards for numeric keypad layouts. Unrec-
ognised order of magnitude errors also frequently occur
due to the proximity of the decimal point and zero
keys.42–44 Unlike computers, general purpose calculators
have no inbuilt system for detecting or preventing user
input errors, and require the user to remember and
correctly apply the appropriate formulae.
The nomogram design embodies the formula and, there-
fore, does not require the user to remember or apply the
formula and constrains the range of data entry and results
to appropriate clinical ranges. Further, nomograms are
declarative, that is, they readily allow reverse and ‘What
if?’ calculations to check data entry and explore the
effects of perturbation of one or more input variables.
This would be extremely difficult to do using the other
systems described above.
As a primary means of calculation, the nomogram would
be particularly useful for clinicians with limited experi-
ence of burns (e.g. in a district general hospital or emer-
gency departments) or for those working in difficult
environments or developing countries.
Cross-checking of calculations is mandatory in other
safety critical fields such as aviation and diving. Two
users should independently perform the calculation
using two completely different techniques – an impera-
tive dedicated computer-based system (e.g. flight or
dive computer), and a declarative dedicated graphic
 490 Bodger et al.

Fig. 4

Response time (s)

Percentile 05 Percentile 25 Median Percentile 75 Percentile 95

Method used: Calculator 51 72 97 131 208

Nomogram 67 88 111 152 207

Pen and paper 102 137 210 282 513

50

40

30
Calculator
20

10

0
50

40
Frequency

30
Nomogram
20

10

0
50

40

30
Pen and paper
20

10

0
0 200 400 600 800
Response time (s)

Descriptives and histogram of the response times for the three different techniques.

device (e.g. nomogram, disc calculator or decompression
table).45 If an electronic device is used as the primary
method of calculation, the nomogram is well suited to
rapidly cross-check the calculation and prevent harm due
to over or under fluid administration.
clinically acceptable limits. The nomogram did not have
the disadvantages associated with electronic devices as
described above and the majority of participants found
the nomogram to be the most intuitive and the easiest
method to use.

Conclusion We, therefore, propose that with appropriate instruction,

The nomogram method for calculation of maintenance
and resuscitation fluid requirements in paediatric burns
by the Parkland formula and ‘4–2–1’ regime was signifi-
cantly superior to pen and paper calculations in terms of
both accuracy and speed of calculation. In comparison
with an electronic calculator, the nomogram was more
accurate and only slightly slower, but well within
the nomogram offers a rapid, accurate and acceptable
means of calculating fluid requirements according to the
Parkland formula and ‘4–2–1’ regime in the first 24 h of
paediatric burns. If an electronic device is used as the
primary means of calculation, the nomogram offers a
rapid means of cross-checking to prevent unnoticed
errors.

Eur J Anaesthesiol 2013; 30:483–491

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It should be emphasised, however, that regardless of the
method of calculation, fluid resuscitation algorithms such
as the Parkland formula are only able to provide a rough
guide to initial fluid administration. Fluid management
should primarily be guided by the individual patient’s
clinical state and response to treatment.
Acknowledgements
Assistance with the study: DW developed the nomograms and
software. AT collected the data. OB performed the power calcu-
lations and statistical analysis and presentation of data. All three
authors designed the study and contributed to the writing and
review of this article. No other persons contributed to the study.
Financial support and sponsorship: none declared.
Conflicts of interests: none declared.
Presentation: Preliminary data for this study were presented as a
poster presentation at the European Society of Anaesthesiology
(ESA) Euroanaesthesia, 9–12 June 2012, Paris.
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