Burn Resuscitation Protocol


Original Date: 07/2017 | Supersedes: 10/2019 | Last Review Date: 01/2021
Purpose: To standardize the resuscitation of adult burn patients.


Recommendations

  • Burn <20% TBSA
    • No formal fluid resuscitation.
    • However, some patients may require IV fluid resuscitation due to pre-injury hypovolemia (i.e. alcohol intoxication, hyperglycemia).
      • If patient has risk factor for requiring IV fluid resuscitation, place a Foley catheter.
    • Provide intravenous fluids as needed to maintain a urine output of 30-50 mL/hour.
      • If the urine output is less than 30 cc/hr for two consecutive hours, notify attending physician.
  • Burn 20-29% TBSA
    • Crystalloid used: Isolyte
    • Starting rate: 2 mL/kg/%TBSA
    • Goal urine output: 30-50 mL/hour
    • Titration: done every hour
      • Urine output <30 mL/hour – increase fluid by 20%
      • Urine output 30-50 mL/hour – maintain current rate
      • Urine output >50 mL/hour – decrease fluid by 20%
    • Fluid boluses: do not bolus

Example: A 70 kilogram man presents to the ED with a 25% TBSA burn. The amount of fluids required would be calculated in the following way:

2mL X Weight
70 kg
X %TBSA
25%
= Estimated total fluid requirements in first 24 hours 3,500 mL

Next, the estimated amount is divided in half to provide the starting rate.

Time Period Volume Rate Round up to nearest 10 mL
First 8 hours 3,500mL/2 = 1,750 mL 1,750 mL / 8 hours = 218.75 mL/hour 220 mL/hour

 

  • Burn ≥30% TBSA
    • Choice of resuscitative fluids:
      • Isolyte, Plasmalyte, or Lactated Ringers
      • Fresh frozen plasma (FFP)
    • Starting rate:
      • Fluid: 2 mL/kg/%TBSA
      • FFP: 0.5 mL/kg/%TBSA/24 hours
    • Goal urine output: 30-50 mL/hour
    • Titration: done every hour
      • Urine output <30 mL/hour – keep crystalloid at current rate and increase FFP by 50 mL/hr
      • Urine output 30-50 mL/hour – maintain current rate of crystalloid and FFP
      • Urine output >50 mL/hour – decrease crystalloid rate by 20% and keep FFP at current rate
        − Begin to decrease FFP/albumin rate by 20% once minimum crystalloid rate has been reached.
    • Fluid boluses: do not bolus crystalloid; however, in cases of hypotension or significant hypovolemia, may consider giving the patient 1 or 2 units of FFP rapidly to correct hypotension from hypovolemia.

Example: A 70 kilogram man presents to the ED with a 50% TBSA burn. As above, the amount of fluid is calculated as follows:

2mL X Weight
70 kg
X %TBSA
50%
= Estimated total fluid requirements in first 24 hours 7,000 mL

Next, the estimated amount is divided in half to provide the starting rate.

Time Period Volume Rate Round up to nearest 10 mL
First 8 hours 7,000mL/2 = 3,500 mL 3,500 mL / 8 hours = 437.5 mL/hour 440 mL/hour

The amount of FFP to be given in addition to the fluid volume above would be calculated as follows:

0.5 mL X Weight
70 kg
X %TBSA
50%
= Estimated FFP amount in first 24 hours 1,750 mL

Next, the estimated amount is divided by 24 to provide the FFP rate.

Time Period Rate Round up to nearest 10 mL
First 24 hours 1,750mL/24 = 72.9 mL 80 mL/hour

So, this patient would be started with fluid at 440 mL/hour and FFP at 80 mL/hour. FFP should be transitioned to 5% albumin at the same rate after 24 hours of resuscitation. Titration of the albumin is the same as FFP.

  • Other considerations during >20% TBSA burn resuscitation
    • Bladder pressure monitoring – notify attending if bladder pressure ≥15 mmHg at any time
    • Glucose management – notify attending if patient has glucose >200 for two consecutive checks
    • Central Line placement – internal jugular and subclavian sites preferred over femoral
    • Arterial line placement – consider in burn TBSA 20-30%, mandatory in TBSA > 30%

Ordering of FFP for Major (≥30% TBSA) Burn Resuscitations

    1. This “Burn Protocol” shall be activated before the transfusion treatment can be proceeded. The activation can be done by calling the TMC blood bank service at 4-3640 by the ordering physician in addition to the EMR order of plasma. The blood bank shall also be notified for the estimated total plasma volume required.
      • The blood bank will use the phone call time as the initiation of the 24-hour protocol time period.
      • The blood bank will try to prepare jumbo plasma units for the activated cases to reduce donor exposures if inventory permitted.
      • The plasma transfusion in such case will considered to be clinically justified based on the approval from the Hospital Patient Blood Management Committee and will not be required for further daily blood utilization review by the pathology team.
    2. The clinical team shall only order the plasma units needed in the following six hours of time period in order to make appropriate clinical adjustment in real-time fashion.
      • The patient’s nurse shall only request the number of plasma units that they plan to complete during her/his shift and within 6 hours at the bedside. A cooler will be issued along with the plasma units released.
      • Only the plasma unit(s) in transfusion shall be out of the cooler and the remaining plasma units shall be stored in the cooler. In general, only one unit of plasma in the transfusion phase is recommended if clinically allowed.
      • Since the cooler required to be re-iced every 6 hours, the clinical team shall return/re-ice the cooler when a new batch of plasma (for the next 6-hour treatment) is requested from the blood bank.
      • The blood bank will provide reminder call for cooler re-icing if the cooler has not been returned 15 minutes prior to the 6-hour from the cooler release.
    3. Even there are existing plasma orders, the release of the plasma unit will be terminated when the 24-hour time period is reached. Any additional plasma transfusion after 24-hours will need to meet the established transfusion indications. Protocol extension requires the communication and discussion between an attending physician from the Burn Service and the pathologist on blood bank service.
    4. The clinical team should take responsibility to return the remaining plasma units and the cooler if the transfusion is terminated as soon as possible to minimize any potential wastage.

Special situation:

  1. Type AB plasma is universal blood component that can be used for medical emergency and there is only 4-5% of population for Type AB, therefore, type AB plasma is usually in shortage. If the burn patient is Type AB, the blood bank will review the inventory both in-house and from the blood supplier. The clinical team will be notified if the plasma supply is insufficient to cover the entire 24-hour need.
  2. Low-titer Type A plasma has been utilized during resuscitation for Type B and Type AB patients per hospital massive transfusion protocol with generally not over 18 units per patient within 24-hours. Our blood bank service doesn’t suggest using ABO-incompatible plasma units in this “Burn Protocol” unless the clinical team determines their use based upon the patient’s clinical condition. A signature consent is required for such order.
  3. During environmental emergency, this protocol may be inactivated depending on the plasma supply. The team leader will be informed with the blood supply status.
  4. When a transfusion reaction occurs, the on-going transfusion shall be hold off till the transfusion reaction work-up is completed. The transfusion reaction investigation shall be initiated as soon as possible.

Background
The purpose of burn resuscitation is maintain tissue oxygenation and perfusion in the setting of intravascular volume loss from increased capillary permeability due to burn shock. Unlike hemorrhagic shock, burn shock causes a slow and steady continuous loss of intravascular fluid (plasma) that occurs first into the thermally injured tissue and then throughout the body.

The best way to manage the this fluid loss is by a slow and steady repletion of the intravascular volume by ongoing resuscitation for the first 24 hours with close monitoring of patient response (i.e. urine output). The classic teaching in the field of burn surgery is that patients with >20% TBSA burns are the only ones that require a formal IV fluid resuscitation.

In general, thermally injured patients with < 20% TBSA burns do not require a formal IV fluid resuscitation since the inflammatory response to burns this size often does not generate a significant capillary leak. These patients can often replete their intravascular volume with PO intake of fluids and at most, may require IV fluids at a maintenance rate to supplement PO fluid intake.

However, there may be cases in which patients are hypovolemic (dehydrated) at admission due to decreased PO intake (i.e. working outside all day in the heat), alcohol intoxication, or hyperglycemia induce diuresis. In these cases, the patient should be started on IV fluids based upon the formula below (2 mL/kg/%TBSA) and have a foley catheter placed for strict I’s and O’s if the patient is unable to assist in monitoring their urine output. The IV fluids should be titrated 10-20% per hour in order to maintain a urine output of 30-50 mL/hr.

For patients with burn injuries > 20% TBSA, the starting IV fluid rate is determined by the Consensus Formula which is 2ml/kg/%TBSA. The recommended IV fluid per the Advanced Burn Life Support course of the American Burn Association is Lactated Ringers, but Isolyte/Plasmalyte may be used instead. This formula estimates the amount of IV crystalloids that the patient would likely require in the first 24 hours after thermal injury.