Burns - Intravenous (IV) fluids

Disclaimer

These guidelines have been produced to guide clinical decision making for the medical, nursing and allied health staff of Perth Children’s Hospital. They are not strict protocols, and they do not replace the judgement of a senior clinician. Clinical common-sense should be applied at all times. These clinical guidelines should never be relied on as a substitute for proper assessment with respect to the particular circumstances of each case and the needs of each patient. Clinicians should also consider the local skill level available and their local area policies before following any guideline.

Read the full PCH Emergency Department disclaimer.

Aim

To guide staff in the use of intravenous (IV) fluids in the child with significant burns.

General

The aims of IV fluids in a child with burns are:

To rehydrate the child with a major burn - total burn surface area (TBSA) (this excludes simple erythema):
- 0-18 months: 8% TBSA and over
- Children > 18 months: 10% TBSA and over
To achieve adequate perfusion of all potentially viable tissue and to maintain function of all vital organs, as evidenced by adequate and not excessive urine output.
All patients with burns requiring admission must be discussed with the Burns Registrar who will discuss with the Burns Consultant.
All patients with significant burns require ongoing close monitoring.

Assessment

Investigations

The following baseline tests need to be obtained if an IV cannula is inserted:

Full blood count, liver function tests, urea, electrolytes and blood glucose level
Venous Blood Gas (VBG) if inhalation burns or carbon monoxide poisoning is suspected
Group and Hold and coagulation profile if other injuries are present
Consider bHCG in female patients.

Management

Resuscitation

If signs of shock, resuscitate with sodium chloride 0.9%, 10-20 mL/kg bolus. Reassess after first fluid bolus and repeat as required.
For more information, consult ED Guidelines Intravenous fluid therapy - ED Guideline.

Initial management

Burns resuscitation fluids according to the Modified Parkland Formula

To be added to the child’s normal maintenance fluids.
Calculate the volume required for fluid replacement using the following formula:
- % TBSA x weight (in kg) x 2 mL
To assess the % TBSA use the Burns Body Surface Area Sheet (PDF).
This gives an estimate of the volume of replacement fluid required in the first 24 hours from the time of the burn (not from time of arrival in hospital).
Administer this calculated volume using Hartmann’s solution as follows:
- 50% within the first 8 hours from the time of burn injury.
- 50% over the next 16 hours.
A urinary catheter should be inserted to monitor urinary output hourly.
Adjustments may be required based on the ongoing assessment of the child.
The Burns Registrar will recalculate the estimated % TBSA during the initial assessment.

Maintenance

Determine child’s normal daily maintenance fluid requirement.
- This is in addition to the Burns Resuscitation fluid, calculated above.
- Maintenance fluid is sodium chloride 0.9% and glucose 5% as pre-mixed solution in 500 mL or 1000 mL bags.
- This rate is only adjusted and/or reduced if the patient is receiving feeds via nasogastric tube (NGT) or tolerating adequate oral fluid.
Consult Intravenous fluid therapy - ED Guideline.

Total fluid requirement calculation:

Total fluid = Burns resuscitation fluid (Burns Fluid Calculator - Modified Parkland formula) + maintenance fluid (given as an hourly rate)

Any volume of fluid given and tolerated orally or by NGT should be deducted from the IV fluid volume that is required to maintain the desired urine output.
Monitor urine output hourly and record and maintain strict fluid balance.

Urine output

As a rule, if a burn is severe enough to require IV fluid resuscitation, then urine output should be properly monitored with a urinary catheter.
Optimal urine output 0.5 – 1 mL/kg/hr for paediatric burns fluid resuscitation patients.
Adjust resuscitation intravenous fluid rate based on urinary output, hemodynamic observations, and patient status in consultation with the Burns Consultant.
- Note that the burns resuscitation fluid (Hartmann’s solution) can be titrated up or down based on urine output, but the maintenance rate (IV sodium chloride 0.9% and glucose 5% + NGT/oral feeds) should remain.
Consult Burns Fluid Calculator - Modified Parkland formula (external site).

Further management

Neurovascular observations

The burn must be elevated to reduce swelling (especially important in circumferential burns).
The neurovascular status must be observed closely and recorded on the appropriate Neurovascular Assessment Chart.
Excessive fluids may result in increasing oedema, possibly compromising the circulation and necessitating an escharotomy.
Early review by the Burns Registrar or Consultant is vital if there are any concerns regarding vascular compromise.

Medications

Consult Burns - Analgesia and dosing - ED guideline.

Bibliography

AMH Children’s Dosing Companion (July 2021) Australian Medicines Handbook Pty Ltd
Textbook of Paediatric Emergency Medicine 3rd Edition Cameron P, Browne GJ, Mitra B, et al (2018) Publisher: Elsevier Edition updated
Nelson Textbook of Pediatrics: 21st Edition Robert M. Kliegman, St Geme JW, Blum MJ et al. 2020 Publisher: Elsevier
Palmieri TL. (2016). Pediatric Burn Resuscitation. Crit Care Clin 32, 547-559.

Endorsed by:	Drug and Therapeutics Committee	Date:	Nov 2021
		Review Date:	Nov 2024

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