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Burn Injury Fluid Resuscitation, Adult (Parkland crystalloid estimate)

Calculators  Multiple body systems
The Parkland cyrstalloid estimate, also known as the Parkland formula, calculates the fluid requirements for acute burn patients for the first 24 hours period from time of burn.
Weight
k
Percent Nonsuperficial Burn Area
%
Result:

Background

Measured Factor
The fluid requirement in patients with major burns.
Measured Factor Detail
The Adult Burn Injury Fluid Resuscitation or Parkland Crystalloid Estimate calculator determines the fluid requirements for patients with major burns during the first 24 hours from time of burn. The calculator does not account for superficial burns. In order to calculate the fluid requirements, the calculator takes into consideration the patient's weight and the estimated percentage of the total body surface area that has been burned, excluding superficial (first degree) burns. In order to calculate the percent of the body, the calculators uses the Rule of 9's for Adults consisting of 9% for each arm, 18% for each leg, 9% for head, 18% for front torso and 18% for back torso. Once the total fluid requirement for the first 24 hours is calculated, the first half must be given during the first 8 hours, while the second half is given over the remaining 16 hours.
Speciality
Multi-Speciality
Body System
Multiple body systems
Formula
Total Crystalloid For First 24 Hours = 4 * Weight * Percent Nonsuperficial Burn Area
Measured Factor Low Impact
  • Low values indicate less fluid requirement is needed.
Measured Factor High Impact
  • Low values indicate less fluid requirement is needed.

Result Interpretation

Ranges Ranges
  • Normal: Results vary according to the patient's weight and percentage of nonsuperficial burn area
  • Normal Adult Male: Results vary according to the patient's weight and percentage of nonsuperficial burn area
  • Normal Adult Female: Results vary according to the patient's weight and percentage of nonsuperficial burn area
  • Normal Geriatric Male: Results vary according to the patient's weight and percentage of nonsuperficial burn area
  • Normal Geriatric Female: Results vary according to the patient's weight and percentage of nonsuperficial burn area
Result Low Conditions
  • Low values indicate less fluid requirement is needed.
Result High Conditions
  • Low values indicate less fluid requirement is needed.
Test Limitations
One of the limitations of the Parkland Formula is its inability to calculate fluid requirements for patients with superficial burns. The calculator does not take into consideration first degree burns and thus can't calculate fluid requirements for patients presenting with these type of burns. Another limitation of this calculator is its limitation to only providing baseline fluid requirements, it has only been validated for the first 24 hours after a burn injury occurs. Fluid needs of burn patients may vary depending on physiologic parameters such as urine output, thus these factors must be taken into consideration when determining the adequacy of fluid resuscitation. Moreover, a study by Blumetti et al found that patients usually received more fluid volume than determined by the Parkland formula.
References: 4, 5

Studies

Study Validation 1
This article described the results of a survey that was designed and given to different burn centers around the world in order to determine what different centers were using as their guidelines for resuscitation. All burn centers were members of the International Society for Burn Injuries (ISBI) and the American Burn Association (ABA). Burn shock resuscitation was described as inadequate in this article published in 2009, due to the tendency to over-resuscitate patients that would results in increased complications. There was a total of 101 respondents, 42 from the ISBI and 59 from the ABA. Surveys were received from everywhere around the world, except Africa and included responses from directors, staff physicians, nurses and others. According to results, initiation of resuscitation occurred when 15% of total body surface area (TBSA) had burns. To calculation the fluid requirements different formulas were used, but the Parkland formula was preferred by 69.3%, others included Brooke (6.9%), Galveston (8.9%), Warden (5.9%) and colloid (11.9%). Responses also varied by the type of preferred fluid used, a majority of centers preferred lactated ringers (91.9%), while others used normal saline (5%), hypertonic saline (4%) and albumin (20.8%) among others. Most of responders (88%) felt their protocols work well and 69.8% of responders felt the right amount of fluid was being used. Overall, most centers appeared to favor using the Parkland formula and lactated ringers as the dominant method for fluid resuscitation.
References: 6
Study Validation 2
This retrospective study compared the actual fluid resuscitation needed by burn patients versus the estimated fluid requirements calculated by the Parkland formula. Patient data was collected from the database of an adult tertiary regional burn center, data corresponded to all admissions between 1998 and 2000. Included patients had to have burns that covered at least 15% of their total body surface area (TBSA) and fluid resuscitation must have been started within 6 hours of injury. Patients with a diagnosis of smoke inhalation injury, concomitant trauma, high voltage electrical injury or incomplete records were excluded from the data. A total of 31 patients were included with a mean age of 51 years and a mean TBSA burn of 27%. The mean 24-hour resuscitation volume was 13,354 mL (6.7mL/Kg/%TBSA) was significantly greater than the predicted amount (P=0.001) and exceeded the estimated volume in 84% of the patients. All patients received significantly more fluid than was predicted with the Parkland formula. Overall, findings demonstrated that despite the effectiveness of the Parkland formula, it still underestimated the volume requirements in most adults with isolated cutaneous burns.
References: 7
Study Validation 3
Non-systematic review article clarifying the instructions for quantifying the amount of fluids needed in resuscitation of burn patients, what the current evidence says about the available solutions, and which solution is most appropriate based on the knowledge available at this time. A two-phase bibliographic search of articles published since 2000 was carried out until 2014, articles retracted up to that date were excluded. A total of 13 studies were published during this time about resuscitation therapy in these patients, but only 11 were included in this review. According to the results of the goal-directed therapy studies, the fluid requirements of burn patients in the first 24 hours is higher than the estimated amount by the Parkland formula. Additionally, studies showed that the initial resuscitation fluid should be a balanced crystalloid. Colloids are not appropriate due the increased capillary permeability in burn patients during the first hours after injury. Hypertonic solutions, albumin and plasma may have a place in fluid resuscitation because they have been associated with lower volume requirements, intra-abdominal pressure and incidence of compartment syndrome. Overall, data for optimal fluid therapy is lacking and further research is needed.
References: 8
Study Additional 1
This retrospective review article analyzed data from 2005 to 2007 to evaluate the effect of adding colloids to the resuscitation protocol for burn victims. The study specifically aimed to evaluate the effects on the development or progression of fluid creep during the initial hours after injury. Fluid creep refers to the progressive increasing crystalloid requirements that arise in burn patients after injury. The data collected consisted of patients who were admitted due to total body surface area (TBSA) burns in 20% or more of their bodies and received formal resuscitation. All patients received resuscitation per the Parkland formula, adjusted to maintain a urine output of 30 - 50 mL/hour. A total of 52 patients were reviewed and 26 of them completed resuscitation using crystalloid alone, while 26 required albumin supplementation (AR). Patients who were managed with crystalloid alone had a mean resuscitation ratio of fluid infusion to urine output of 0.13-0.40, while AR patients had progressively increasing ratios that reached a maximum of 1.97, until albumin was administered. After starting albumin there was a dramatic and precipitous return of ratios to predicted ranges. No patients developed abdominal compartment syndrome. In conclusion, adding colloids to the Parkland resuscitation reduces the hourly fluid requirements, restores normal resuscitation ratios and ameliorates fluid creep.
References: 9
Study Additional 2
This prospective, randomized study aimed to evaluate the effects of plasma resuscitation fluids on intra-abdominal pressures in burn patients. It is suggested that the volume of resuscitation given to burn patients may contribute to the level of intra-abdominal pressure in patients with intra-abdominal hypertension (IAH) and/or abdominal compartment syndrome (ACS). As a result, some have suggested that using plasma resuscitation minimizes early weight gain when compared to crystalloid resuscitation. Thus, it is possible that plasma resuscitation may be protective from ACS and affect mortality. A total of 31 patients were prospectively identified and followed, patients had burns with 25% of total body surface area (TBSA) with inhalation injury or 40% TBSA without inhalation. Patients were assigned to receive crystalloid (Parkland formula) or plasma resuscitation. The IAP was measured by means of urinary bladder transduction. Results showed that there was a greater increase in IAP with crystalloid resuscitation than with plasma (26.5 vs. 10.6 mmHg, p<0.0001). More fluid volume was required in patients receiving crystalloid resuscitation (0.26 L/kg vs 0.21 L/kg, p<0.005) and only 1 patient in the crystalloid group was able to maintain IAP less than 25 mmHg. In conclusion, the study showed patients receiving plasma resuscitation were able to maintain an IAP below the threshold of complications and this could potentially be due to the decrease in volume requirement of these patients.
References: 10
Study Additional 3
This retrospective review article evaluated the associated change in pre-hospital fluid administration when adopting the Alfred pre-hospital fluid isotonic crystalloid resuscitation formula for major burns. This formula recommends crystalloid fluid requirement in the first 2 hours after injury and it consists of the body weight (kg) x % total body surface area (TBSA) burnt. When compared with the Parkland formula, the Alfred formula predicts twice the volume. This review looked at the records of patients with major burns that presented to the Alfred Emergency & Trauma Centre over a 10-year period. From this review, a total of 126 patients were included in the review based because they had major burns (≥ 20% TBSA). The fluid resuscitation and outcomes for patients was compared in the period before the introduction of the new formula  to those in the post-introduction time.  Results showed that in 24 hours the volume of fluid administered in patients per the Alfred formula was not significantly higher than the volume administered before the formula was implemented (4.9 ± 1.6 mL/kg/%TBSA vs. 4.8 ± 2.2 mL/%TBSA/kg, p=0.802, respectively). The median fluid volume administration pre-hospital after introduction of the Alfred formula was 0.35 mL/Kg/%TBSA, which was significantly higher than 0.14 mL/kg/%TBSA administered in the prior period (p=0.013). There was no significant change in physiological endpoints associated with the increased volume. In conclusion, the Alfred formula resulted in patients receiving more fluid early, but still below the recommended amount as set by the Parkland formula. No adverse effects were found, and thus the Alfred pre-hospital fluid formula appears to be safe and effective.
References: 11

Authors

Charles R. Baxter, MD, received his medical degree from the University of Texas Southwestern Medical School in 1954. He became a research investigator at Brook Army Hospital in 1956, from which he was discharged in 1958. He became the director of the Parkland Burn Center in 1961. Dr. Baxter received numerous awards, including the American Burn Association's Harvey Stuart Allen Distinguished Service Award for lifetime outstanding service in the field of burns.
http://obits.dallasnews.com/obituaries/dallasmorningnews/obituary.aspx?n=charles-r-baxter&pid=3278690&fhid=2584

References

  1. Baxter CR, Shires T. Physiological response to crystalloid resuscitation of severe burns. Ann N Y Acad Sci, 1968;150:874-894
  2. Baxter C. Fluid resuscitation, burn percentage, and physiologic age. J Trauma. 1979 Nov;19(11 Suppl):864-5
  3. Baxter CR. Fluid volume and electrolyte changes of the early postburn period. Clin Plast Surg. 1974 Oct;1(4):693-703.
  4. Baxter CR. Fluid volume and electrolyte changes of the early postburn period. Clin Plast Surg. 1974 Oct;1(4):693-703.
  5. Blumetti J, Hunt JL, Arnoldo BD, Parks JK, Purdue GF. The Parkland formula under fire: is the criticism justified? J Burn Care Res. 2008 Jan-Feb;29(1):180-6.
  6. Greenhalgh DG. Burn resuscitation: the results of the ISBI/ABA survey. Burns. 2010 Mar;36(2):176-82.
  7. Cartotto RC, Innes M, Musgrave MA, Gomez M, Cooper AB. How well does the Parkland formula estimate actual fluid resuscitation volumes? J Burn Care Rehabil. 2002 Jul-Aug;23(4):258-65.
  8. Guilabert P, Usúa G, Martín N, Abarca L, Barret JP, Colomina MJ. Fluid resuscitation management in patients with burns: update. Br J Anaesth. 2016 Sep;117(3):284-96.
  9. Lawrence A, Faraklas I, Watkins H, Allen A, Cochran A, Morris S, et al. Colloid administration normalizes resuscitation ratio and ameliorates "fluid creep". J Burn Care Res. 2010 Jan-Feb;31(1):40-7.
  10. O'Mara MS, Slater H, Goldfarb IW, Caushaj PF. A prospective, randomized evaluation of intra-abdominal pressures with crystalloid and colloid resuscitation in burn patients. J Trauma. 2005 May;58(5):1011-8.
  11. Mitra B, Fitzgerald M, Wasiak J, Dobson H, Cameron PA, Garner D, et al. The Alfred pre-hospital fluid formula for major burns. Burns. 2011 Nov;37(7):1134-9.