Resuscitation of Severely Burned Military Casualties: Fluid Begets More Fluid

Background: In November 2005, institution of a military-wide burn resuscitation guideline requested the documentation of the initial 24-hour resuscitation of severely burned military casualties on a burn flow sheet to provide continuity of care. The guidelines instruct the providers to calculate predicted 24-hour fluid requirements and initial fluid rate based on the American Burn Association Consensus recommendation of 2 (modified Brooke) mL . kg(-1) . % total body surface area (TBSA)(-1) to 4 (Parkland) mL . kg(-1) . %TBSA(-1) burn. The objective of this study was to evaluate the relationship between the estimated fluid volumes calculated, either by the Modified Brooke or the Parkland formulas, and actual volumes received. Methods: From November 2005 to December 2008, 105 patients were globally evacuated with >20% TBSA burns, of whom 73 had burn flow sheets initiated. Of these, 58 had completed burn flow sheets. Total fluids administered in the first 24-hour period for each patient were recorded. Chart reviews were performed to extract demographic and clinical outcomes data. Results: Of the 58, the modified Brooke formula was used in 31 patients (modified Brooke group) to estimate 24-hour fluid requirements and the Parkland formula was used in 21 (Parkland group). In six, 3 mL . kg(-1) %TBSA(-1) was used and were excluded from analysis. No significant difference was detected between the two groups for age, %TBSA burned, inhalation injury, or Injury Severity Score. Actual 24-hour resuscitation in the modified Brooke group was significantly lower than in the Parkland group (16.9 L +/- 6.0 L vs. 25.0 L +/- 11.2 L, p = 0.003). A greater percentage of patients exceeded the Ivy index (250 mL/kg) in the Parkland group compared with the modified Brooke group (57% vs. 29%, p = 0.026). On average, those who had 24-hour fluid needs estimated by the modified Brooke formula received a 3.8 mL . kg(-1) . %TBSA(-1) 1.2 mL . kg(-1) %TBSA(-1) resuscitation, whereas the Parkland group received a 5.9 mL . kg(-1) . %TBSA(-1) +/- 1.1 mL . kg(-1) . %TBSA(-1) resuscitation (p < 0.0001). No differences in measured outcomes were detected between the two groups. On multivariate logistic regression, exceeding the Ivy index was an independent predictor of death (area under the curve [AUC], 0.807; Cl, 0.66-0.95). Conclusion: fit severely burned military casualties undergoing initial burn resuscitation, the modified Brooke formula resulted in significantly less 24-hour volumes without resulting in higher morbidity or mortality.