CRYSTALLOID FOR THE MANAGEMENT OF BURN

SHOCK: A RIGHT CHOICE.

MEDICAL CHANNEL JULY-SEPT 2007. VOL 13(3) 106-
110.

CRYSTALLOID FOR THE MANAGEMENT OF BURN

SHOCK.
A RIGHT CHOICE?

ABSTRACT: A prospective study; with primary object of standardizing

resuscitation regimen and at the same time; to evaluate the adequacy of parkland
formula and efficacy of Crystalloid to manage Burn shock was conducted at Burn Unit,
Liaquat University of Medical & Health Sciences; from March 2005 to August 2006. The
data of 100 adults (Mean age 29.20 years and mean BSA affected was 47.33 %) and 50
children (mean age of 7.350 years, with mean BSA of 30.37%) was analyzed. Result
showed that Parkland formula provide a good starting point but needs must always be
individualized. The adult patients having below 50% BSA involved and Children below
60% BSA burn required on the average 0.045 ml/% BSA burn more fluid (Paired t-test
P=0.000, P=0.000) then calculated while and almost mirror image was note when BSA
affected was more then 50% in adult and 60% in children where fluid infused was on
average 0.042 ml/% BSA was less then the calculated fluid (Adult P = 0.000, children P=
0.171). The efficacy of crystalloid to manage burn shock was assessed by the death
with in the 1st week of admission and results showed only 15.34% mortality which is
comparable to the mortality rates of other series where albumin was use to mange the
burn shock. We therefore conclude that parkland formula is only a template and need
must always be individualized; while Ringers’® solution; a much economical fluid is no
way inferior to manage the burn shock adequately.

Category: Burn

Key words: Shock, Crystalloid, Ringers’ Lactate, Parkland Formula.

INTRODUCTION: All patients of major burn presents with hypovolaemic shock.
Burn shock is hypovolaemic and cellular in nature, and is characterized by specific
haemodynamic changes, including decreased cardiac output, extracellular fluid and
plasma volume, and oliguria. Multiple mediators have been proposed to explain the
changes in vascular permeability. The mediators proposed produce an increase in
vascular permeability or increased microvascular hydrostatic pressure. The end result is
a disruption of the normal capillary barriers separating intravascular and interstitial
compartments and rapid equilibrium between these compartments. Plasma volume is
severely depleted, being clinically manifested as hypovolaemia, with a marked
increase in extracellular fluid.

It is well know that the early management of major burns improves survival.1-
3.Immediate burn care involves airway management and fluid resuscitation, the most

important period being the first few hours after the burn injury. The resuscitation of major
burns involves the administration of large volumes of fluids calculated on the basis of
burn surface area and body weight, and different burn centers use different formula
depending on their own clinical experiences .

In 1901 Parascondolo of Naples emphasizes the importance of salt-containing fluid in

the early post burn period4. Soon in United States same was proposed by Haldor Sneve
in 19055. In 1910 Harkin proposed first formula for fluid replacement based on burn
extent 6, which later adopted by the United States National Research Council 7. This
formula and those proposed by Cope and Moore 8 and of Evans et al9 emphasized
colloid-containing fluids for volume replacement in the immediate post burn period.
However the work of Moyer et al 10 and Baxter11 soon brought to light the importance of
the sodium/potassium pool and the contribution of the Na+ ion in the intra- and extra-
cellular distribution of electrolytes and water. In 1968, Baxter and Shires12 emphasized for
the use of a greater volume of balanced salt solution and introduced Parkland formula.
Since then despite research and debate, 9, 13,14,15,16, we still do not have A PERFECT
FORMULA that can determine EXACT fluid volume necessary to prevent complications
and yet avoid at the same time over-hydration.

The Parkland formula, as proposed by Baxter is shown in table No 117.

TABLE No: 01
 Parkland formula for burns resuscitation

Total fluid requirement in 24 hours =

4 ml×(total burn surface area (%)) × (body weight (kg))
50% given in first 8 hours
50% given in next 16 hours
Children receive maintenance fluid in addition, at hourly rate
of
4 ml/kg for first 10 kg of body weight plus
2 ml/kg for second 10 kg of body weight plus
1 ml/kg for > 20 kg of body weight
End point
Urine output of 0.5-1.0 ml/kg/hour in adults
Urine output of 1.0-1.5 ml/kg/hour in children

AIM OF STUDY: The primary object is to standardize resuscitation regimen at

our centre and at the same time it will provide opportunity to experience the efficacy
of crystalloid to manage post burn shock & to find out the adequacy of Parkland
formula. We as tropical country have different climatic conditions and as a matter of
fact our population has different genomic configuration, general physique and
socioeconomic status. So far no local study has ever been conducted on the subject.

DESIGN OF STUDY: A prospective observational study conducted at Burn

Emergency Unit, Department of Plastic Surgery; Liaquat University of Medical & Health
Sciences Jamshoro.

DURATION OF STUDY: This study carried out for a period of 1 year from Feb 2006 to
Jan 2007.
PATIENTS & METHODS: The study comprised 150 (50 children and 100 adults) burn
patients admitted to the Burn Unit of Liaquat University of Medical & Health Sciences
Jamshoro (Pakistan) with burns exceeding 10 % total body surface area (TBSA); whether
Flame burn or Scalds.

Exclusion criteria

1. Burns involving less than 10% TBSA

2. Patients presenting with chemical/electrical burns as these has unique aspects.
3. Patients with associated injuries
4. Patients with history of pre-existing renal disease or serum creatinine above 2
mg/dl at the time of admission.
5. Patients presented more then 12 hours after the incidence.
6. Patients with history of Diabetes Mellitus/Hypertension.

Fluid regimens.

Total body Surface area burn is calculated using Lund & Browder Charts 18. The body
weight is assessed using a weighbridge. The I/v line maintained with 18 gauge I/V
cannula & an indwelling Foley’s catheter passed .The first 48 post-burn hours are
divided into six 4-hour periods in order to facilitate the nursing routine and eliminate
possible complications arising from the large volumes of fluid infused. Then the amount
of fluid to be infused over first 24 hours is calculated according to PARKLAND’S
FORMULA (4 ml/Kg/% TBSA), and subsequently adjusted to maintain optimum urine
output (1.5ml/Kg/Hour in children and 1 ml/Kg/Hour 17 or 50-100 ml/Hour in adult 19). The
higher limit of the urine output was chosen due to previous experience of high
incidence of acute renal failure. The 50% of calculated amount infused within 8 hours
and the other 50% in next 16 hours as shown in table No 2.

Due to the time limited nature of the changes in capillary permeability, the aim after
the first 24 hours post burn is to expend the intravascular volume and provision of daily
maintenance fluids plus any losses ( for e.g. vomiting, nasosgastric aspiration). For the
next 24 hours; with aim to expend the intravascular volume we infuse artificial colloid
HAEMACCEL® 0.5 ml/Kg/% BSA plus 1ml/Kg/% Burn of 5% D/S for adults and 5% D/W in
0.45 Saline for Children. It has recently been shown that HAEMACCEL® can safely be
use even in neonates 20. The calculated amount of Inj: HAEMACCEL® infused in first 8
hours and the maintenance fluids over the next 16 hours as shown in table No 3.

1st 24 Hours
TABLE No: 02
Total Fluid Calculated according to PARKLAND FORMULA and adjusted according to Urine output.
 Fluid use Inj: Ringer’s Lactate only.

riod

TABLE No: 03

2nd 24 Hours

Total fluid Calculated, 0.5 ml/Kg/ % BSA for Artificial colloid &

1.0 ml/Kg/% BSA for Crystalloid.

Artificial Colloid= Inj: Haemaccel

Crystalloid= 5% Dextrosaline for Adults and 5% Dexrose in

0.45% Saline for children.

6th Period

12.5%
INJ: HAEMACCEL INJ: 5% Dextrosaline for Adults &

1st & 2nd Period 5% Dextrose water in 0.45% Saline for

Children. 3rd to 6th periods

After 48 hours we continue with the maintenance fluids without Inj: HAEMACCEL® for
another 5 days.

Adequacy of resuscitation

Various parameters are suggested, but many are simply of academic interest and did
not provide practical benefits to patients and therefore we choose fallowing
parameters;

Pulse rate.
Mean arterial pressure.
Urine output 1ml/Kg/hour (0r 50 -100 ml/Hour) in adults and 1.5 ml/Kg/Hour
in children weighing up to 30 Kg; reading taken every 4 hourly; However in
children weighing above 30 Kg the urine output was maintain at adult
level 21.
Haematocrit; estimated on admission and every 6 hourly for 48 hours, and
then daily for next 5 days.

The studied variables were evaluated on admission of the patients, and were
considered the pre-infusion values. Thereafter these variables were re-evaluated 6, 12,
and 24 h after initiation of fluid therapy.

Death within the first week of admission is considered to be the failure of resuscitation12.
Hypothesis: The Parkland formula suited for all age group presenting with different major
burn in our climatic conditions.

Alternate Hypothesis: The Parkland formula in not adequate for all patients

Alternate Hypothesis: The parkland formula is more then adequate for some patients.

Statistical analysis .

Data were presented as means and Percent. The statistical analysis of demographic
data (age, sex distribution, TBSA, percentage burned TBSA) was performed using one-
factor analysis of variance. Different groups were compared for changes occurring in
the studied variables using the two-tailed t-test and within group paired t-test was used.
The level of significance was set at a p value <0.05. Computations were performed
using the statistical software package Minitab ® 15 of Minitab Inc.

RESULTS: Our 1st group comprises of 50 paedterics patients having mean

age of 7.350 years (ranges1-12 years), with 37(74%) boys and 13 girls (26%). Their mean
body weight was 24.80 Kg (ranges from 8.50 Kg to 44 Kg).

The mean body surface area involved was 30.37% (ranges from11.5% to 63.5%).

The mean age of 100 adult patients was 29.20 years (ranges13 to 65 years).58 males
(58%) & 42(42%) females. Their mean body weight was 62.240 Kg (ranges between 34 to
82 Kg). The mean body surface area involved was 47.33 % (min15.5 & max 96%). The
male to female ratio is shown in chart No 01.

CHART No: 01
 SEX RATIO
ADULT BURN PATIENTS
PAEDRITICS BURN PATIENTS

Sex Adult Sex Category

FEMALE
MALE

26.0%

42.0%

58.0%

74.0%

Due to wide variations in BSA affected , fluid calculated and amount actually infused,
data will be consider in accordance with the %BSA affected. The P-value was set at
0.05 with alternate hypothesis that fluid infused and fluid calculated are not equal.

Fluid Infused Versus Fluid Calculated:

In practice, to get the urine output of 1.5 ml/Kg/Hour or more; for peads patients the
fluid infused was much greater then that calculated. The mean amount infused during
first 24 hrs was 4153 ml (min 940ml & max10530ml) was in quite contrast to that
calculated; (Mean 3386ml min 612ml & max10032ml) as can be seen from table No 4.
The highest fluid requirement is seen in pts presented with 11-20% ( approx 55.45% more
fluid) while for others group it was 43.70% more for 21-30%; Approx 31.20 % more for 31-
40% ,about 13.98% for 41-50% and approx 7.90% for 51-60%. While for 61-70% we
observe about 9.01% reduction. The p-value for different groups was also significant.
 TABLE No: 04

%BSA No Mean Mean Mean Mean P-

Fluid Fluid Factor Value
Affected Of Body
Pts Wt Calculate Infused Difference

11-20% 16 17.78 1169 1762 +2.21675 0.009

21-30% 12 22 2154 3074 +1.748 0.001

31-40% 10 28.25 3963 5177 +1.2478 0.005

41-50% 6 32 5891 6673 +0.5595 0.238

51-60% 4 36.50 7987 8604 +0.31625 0.701

61-70% 2 35.50 8921 8175 -0.3605 0.645

Total 50

For adult patients mean fluid infused was 10553 ml ranging from 3295 ml to 15245 ml in
contrast to mean fluid calculated 12110 ml ranging from 2312 ml to 30176 ml as shown
in table No 5. Again the fluid requirement for patients with 11-20% burn was highest
(41.52% more then the calculated fluid), for 21-30% it was 32.97%; for 31-40% it was
19.31%; for 41-50% it was 9.26% additional fluid. On the other hand for more then 50%
BSA burn we notice that infused fluid was less then the calculated fluid. For 51-60% BSA
we found 3.6% reduction; for 61-70% BSA it was 17.20%; for 71-80% it was 30.27%; for 81-
90% BSA it was 43.20% and for 91-100% burn fluid requirement was least (55.19% less then
the calculated fluid).

TABLE No 05

%BSA No Mean Mean Mean Mean P-

Fluid Fluid Factor Value
Affected Of Body
Pts Calculate Infused Difference
Wt

11-20% 14 52.79 3755 5308 1.6608 0.000

 21-30% 20 61.85 6129 8096 1.3191 0.000

31-40% 12 64.75 9164 10880 0.7725 0.045

41-50% 10 59.80 10564 11491 0.3707 0.321

51-60% 12 64.42 13835 13263 -0.1439 0.203

61-70% 10 63.20 16352 13527 -0.6877 0.000

71-80% 08 65.50 19480 13534 -1.21075 0.000

81-90% 08 65 22005 12457 -1.72825 0.000

91-100% 06 70.67 26465 11873 -2.208 0.000

100

Early Mortality:

As a general census the death during first week of admission is consider to be the failure
of resuscitation, though the death may apparently be due to other causes. During first
week of admission, in our series 23(15.34%) patients expired; as shown in table No 6.

TABLE No: 06

Peads Adult Total Mean BSA% Mean

Age(Yrs)
M F M F

Acute renal failure - - 2 1 3 68.34% 50.67%

Cerebrovascular 1 - - 1 67.0% 62
accident

Cardiopulmonary 3 - 3 2 8 41.17% 10.67

arrest Peads Peads

56.2% adult 34 adults

Severe inhalation 1 1 2 1 5 47% 7

 injury 44.17% 42.34

Aspiration - - 1 1 18% 1
pneumonia

Multiple organ 1 1 1 2 5 59.5% 10.75

failure
84.67% 22.34

Total 6 2 8 7 23

The most common cause of death was cardiopulmonary arrest (34.78%) fallowed by
respiratory failure due to inhalation injury (21.74%) and the multiple organ failure
(21.74%). The other causes were acute renal failure in 3 cases (13.05%), aspiration
pneumonia in 1 case (4.35%) and cerebrovascular accident (4.35%) in 1 case as seen in
chart No 2.

CHART No: 2

CAUSES OF DEATH
ADULT & CHILDREN

Cause of Death
Acute Renal Fialure
3, 13.0% Cerebrovascular Accidents
Cardiopulmonary Arrest
5, 21.7%
Severe Inhalation Injury
1, 4.3% Aspiration Pneumonia
M ultiple Organ Failure

1, 4.3%

8, 34.8%
5, 21.7%

Parameters evaluating the efficacy of fluid administration:

1: Urine output.
For our peads patients; the urine output was maintained at or greater then
1.5ml/Kg/Hour, while for patients above 30 Kg it was maintain according to the adult
patients. Mean urine output for first 24 hours after admission was 1.52 ranging from 1.32
to 1.58 ml/Kg/Hr, while mean urine output for next 24 hours was 1.5 ml/Kg/Hr.

For adult patients the mean urine output during first 24 hrs was 69.360

Ml/Hr (mean body weight was 62.240 Kg) and for the next 24 hours it was 69.670 ml/Hr.

2: Heamatocrit.

For group 1 pts the mean for 1st 24 hours was 47.520 (Min42-Max52) while for next 24 hrs
it was 42.520 (Min 40- Max 46). For group 2 pts the mean Hct for first 24 hours was 59.030
(Min 44.00 Max 78.00) while for the next 24 hours it was 49.140 (Min 38.0 Max
54.0)

3: Serum Potassium.

The serial measurement of serum K+ performed for each patient of both group. Mean
serum potassium for peads patients during 1st 24 hours was 5.4 mEq/L while for next 24
hours it was 4.3 mEq/L; and for adult patients it was 6.1 mEq/L and 4.7 mEq/L, resp.

4: Pulse rate.

Pulse rate was monitor regularly during the entire period of resuscitation every 4 hour
and was almost the mirror image of the urine output i.e. as the urine output gradually
improves the pulse returns to normal. In 70% cases it was after completion of the 1st
phase (within 08 hours) of resuscitation, when 50% of the calculated fluid has infused.

DISCUSSION: Burns injuries generate an inflammatory response to the injured tissue

proportional to the burn surface area. Major Burns require intravenous fluid resuscitation
to treat hypovolaemia secondary to increased capillary permeability. Recognition of
the time limited nature of the changes in capillary permeability led to the development
of fluid resuscitation formulas to provide a template from which individual fluid
requirements could be adjusted. Plasma protein loss into the extra cellular space
dictates colloid fluid replacement at some point in the resuscitation regimen—debate
continues as to the nature and timing of an optimal fluid regimen.

This understanding of haemodynamic changes has lead to the development of various

regimes to resuscitate major burn, with resultant marked reduction in mortality &
morbidity. This study was based what we use in our setup to resuscitate these patients.

While considering the adequacy of parkland formula, the results of our study showed
that it is both inadequate and more then adequate. The fluid practically infused to
patients having BSA affected less then 50% in adult and less then 60% BSA in children
was much greater then the fluid calculated based on parkland formula. Mean fluid
infused for children was 3985 ml as compared to mean fluid calculated 3156 ml, Paired
t-test P=0.000 , while mean fluid infused for adult patients 8602 versus mean fluid
calculated 6978 ml, P=0.000. However we observed mirror image in patients presented
with burn involving more then 50% BSA in children and more then 60% BSA in children.
The mean fluid infused to adult was 13036 ml versus 18641 ml calculated fluid P = 0.000;
for children mean fluid infused was 8175 versus 8921 ml calculated amount P= 0.171. It is
very difficult to give a simple explanation of the above finding as probably various
factors are operative.

On the average we observed 0.045ml increment for every % burn when BSA affected
was less then 50% & 60% in adult and Children respectively. Similarly decrement of 0.042
ml for every % burn noted for Burn involving more then 50% & 60% BSA in adult and
children respectively.

Hyderabad city is Located at 25.367°N latitude and 68.367°E longitude with an

elevation of 13m about sea-level 22. Hyderabad has an extreme climate. In summer
days are hot and dry usually with min 27.1°C to max 40.9°C, while in winter it is min
11.8°C to 25.6°C max 23. This climatic condition probably demanded more fluid.

Hyperpyrexia is common in burn patients especially in children whose thermoregulatory

system is not fully matured. This could be another factor requiring incresed fluid.

However when analyzing decresed fluid requairments when BSA affected was more
then 50% & 60% in adult & children respectively, the only possible explanation cuold be
that; as the BSA affected is incresed the ratio of deep to superficial burn steaadily
increasd and as a matter of fact superficial burn are always more exudative as
compared to deep burn.
Of the parameters evaluationg the efficacy of the crystalloid to manage acute burn
shock, the result of this study showed that despite the large load of Na+, K+, and the
serum potassium level that showed moderate increase during the first 24 hours returns
well within the normal limit over the next 24 hours in both groups.

The urine output showed a small, insignificant increased after the first 24 hours; probably
due to the infusuion of colloid.

The heamotocrit remained at high levels, despite the administration of large fluid
volumes throughout the first 24 hours; it showed steady reduction after the
administration of artificial colloid and maintenance fluid at the beginning of the second
24 hours.

When comparing crystalloid with albumin with respect to mortality, the current census is
that the use of albumin does not reduce the risk of death, instead it may be associated
with an increased risk 24, 25. The cost of management when resuscitation done with
albumin also increases tremendously without any added advantage. The result of this
study also favors the same finding when overall mortality of this series {15.34% (23/150} is
compare with those where albumin/HPPF was use as resuscitative fluid with invasive
monitoring, 26, and 27,,28,29,30,31.

The most common complication associated with infusion of such large amount of
crystalloid , like pulmonary edema, heart failure, compartmental syndrome were not
seen in any of our patients.

The causes of death; within 1st week of admission; reflecting failure of the resuscitation;
in this series was cardio-pulmonary arrest (34.78%) fallowed next by severe inhalation
injury and multiple organ failure (21.74% each). The acute renal failure was the terminal
event in 3 cases (13.04%), while 1 patient expired due to inhalation pneumonia and 1
case developed accelerated hypertension on 4th post burn day ;without past history of
hypertension; leading to cerebrovascular accident that lead to his death. When
considering each death at its own in view of haemodynamic derangement in major
burn then only 08 deaths (5 due to multiple organ failure and 3 due to acute renal
failure) can directly be attributed to failure of resuscitation.

Conclusion:

We conclude that the Parkland formula should always be consider just a starting point
and the amount required to resuscitate must always be individualized. Urine output
should always be maintain at upper limit i.e. aim should be to have ADEQUATE output
rather then SUFFICIENT. The results we achieved with crystalloid are in no way inferior to
those centers where human albumin/colloids are use for resuscitation.
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