• 
• 

Three Part Question

In [adult patients with burn injury] which [fluid resuscitation formula] provides the [best outcome from resuscitation]?

Clinical Scenario

A 35 year old man has been trapped in a burning building and suffered extensive burns over his chest and legs. He requires fluids and you start fluid therapy based on the Parkland formula. You wonder if this formula will provide sufficient fluids for resuscitation.

Search Strategy

Medline using the OVID interface 1966-06/05.
[exp BURNS/ or burn$.mp. or thermal burn$.mp.] AND [fluid formula.mp. or fluid$.mp. or Parklands formula.mp. or exp Fluid therapy or Baxter formula.mp. or Mount Vernon formula.mp.] AND [exp RESUSCITATION/ or resuscitation.mp. or resuscitation$.mp] LIMIT to human AND English Language

Search Outcome

345 papers were found of which 4 were relevant

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
Friedrich JB. Sullivan SR. Engrav LH. Round KA. Blayney CB. Carrougher GJ. Heimbach DM. Honari S. Kl 2004 USA	Two cohorts of patients. Group 1-11 patients admitted between 1975 and 1978. Group 2-11 patients admitted in 2000.	Retrospective chart review	Fluid received in first 24 hours	Group 1- 3.6+/-1.1cm3/kg/%TBSA burned. Group 2- 8.0+/-2.5cm3/kg/%TBSA burned. Difference between the two groups is significant p<0.001	Small number of patients were used. No outcomes given ie. did patients suffer or benefit from these large fluid volumes.
			Urine output	No statistical difference in urine output
Murison MS. Laitung JK. Pigott RW. 1991 UK	Adults admitted to the burns unit.	Retrospective study	Fluid therapy given in both years. 1988-93 patients. 1989-82 patients	Volume of fluid exceeded the calculated requirement after 12 hours. A statistically significant difference is observed (student t-test p<0.05)	Resuscitation volumes started at outlying emergency departments have not been included
Cartotto RC. Innes M. Musgrave MA. Gomez M. Cooper AB. 2002 Canada	31 patients admitted to burns centre. Inclusion criteria-presence of burns>=15%TBSA, fluid resuscitation started within 6 hours of injury. Patients with inhalation injury, electrical injury or associsted trauma were excluded.	Retrospective cohort study	Total resuscitation volume for first 24 hours	13 354+/-7386ml - significantly greater than Parkland estimate of 8227+/-3239ml (p<0.001)	Small number of patients. No comparison with other methods of fluid resuscitation.
			Best outcome from resuscitation	All patients were resuscitated successfully.
Holm C. Mayr M. Tegeler J. Horbrand F. Henckel von Donnersmarck G. Muhlbauer W. Pfeiffer UJ. 2004 Germany	50 consecutive patients during a three year period (1999-2002) admitted to an intensive care burn unit with severe burns. Inclusion criteria-TBSA>20%, admission to burn unit within 8 h of thermal injury and fluid infusion started within 6 h of injury. Control group-resuscitated according to Baxter formula. TDD group-treated according to a volumetric preload endpoint obtained by invasive haemodynamic monitoring.	Randomised Controlled Trial	Fluid infusion, first 24 h	Control Group-mean of 16,232ml. TDD Group-mean of 27,064ml. Statistically significant p=0.0001. Mean Parkland fluid estimate, 15,988ml.	Study population was too small
			Multiple organ failure	10 patients in both groups
			Mortality	Control group-10 patients, TDD group-8 patients. Not statistically significant.

Comment(s)

Fluid resuscitation of burns patients remains a double edge sword. The basic problem of burn shock resuscitation is caused by the capillary leak which condemns every attempt to restore intravascular volumes without causing overinfusion and oedema. A recent RCT has shown that the commonly used Parkland formula provides sufficient fluids for resuscitation but evidence before this has shown it to underestimate the amount of fluids required. However, the RCT is a recent high level of evidence and therefore carries more weight than the other studies mentioned.

Clinical Bottom Line

There is no evidence that resuscitation using different regimes provides a better outcome than fluid replacement using the Parkland formula.

References

1. Friedrich JB. Sullivan SR. Engrav LH. Round KA. Blayney CB. Carrougher GJ. Heimbach DM. Honari S. Klein MB. Gibran NS Is supra-Baxter resuscitation in burn patients a new phenomenon? Burns 30(2004) p464-466
2. Murison MS. Laitung JK. Pigott RW. Effectiveness of burns resuscitation using two different formulae. Burns (1991) p484-489
3. Cartotto RC. Innes M. Musgrave MA. Gomez M. Cooper AB. How well does the Parkland formula estimate actual fluid resuscitation volumes? J Burn Care and Rehabilitation 23(2002) p258-265
4. Holm C. Mayr M. Tegeler J. Horbrand F. Henckel von Donnersmarck G. Muhlbauer W. Pfeiffer UJ. A clinical randomized study on the effects of invasive monitoring on burn shock resuscitation. Burns 30(2004) p798-807