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This research reviews determinants of fluid distribution in burn patients, focusing on evaporative water loss.

April 18, 2026European Burn Journal0 citationsOpen Access

From Evaporation to Edema: A Scoping Review of Physical and Biological Determinants of Early Fluid Distribution in Burn Patients

SASergio ArlatiOspedale Maggiore PAPaolo Aseni

Key Points

This research reviews determinants of fluid distribution in burn patients, focusing on evaporative water loss.
Conducted a scoping review of historical and contemporary studies on major-burn resuscitation.
Estimated expected TEWL from benchmarks and assessed interstitial edema from fluid input and weight change.
Developed a novel TEWL/edema ratio to evaluate fluid management strategies.
Median TEWL was 71 mL/m2/h in burned individuals during the acute phase.
The TEWL/edema ratio correlates inversely with resuscitation fluid dose and input/output ratio.
A ratio greater than 1 indicates potential under-resuscitation, while a ratio less than 1 suggests fluid retention.

Abstract

Background: Evaporative water loss from burn wounds is a major but often neglected component of early fluid requirements. Despite its physiological importance, no dedicated review has quantified acute post-burn evaporative water loss (TEWL) and its interaction with modern resuscitation strategies in over 40 years. Recent mass-casualty burn events in specialized centers have re-emphasized the clinical importance of accurate early fluid balance, which is particularly challenging. Methods: A scoping review (PRISMA-ScR) of historical quantitative studies and 23 contemporary (2015–2025) adult major-burn resuscitation cohorts was conducted. Expected TEWL was derived from Lamke benchmarks; interstitial edema was estimated from the only available regression of simultaneous fluid input and 24 h weight change. A novel TEWL/edema ratio was tested against resuscitation volume (mL/kg/%TBSA) and the established input/output (I/O) ratio. Results: In the acute phase, the median TEWL normalized to total body surface area was 71 mL/m2/h 52–79 mL/m2/h, allowing for calculation of the TEWL/edema ratio. The TEWL/edema ratio was inversely correlated with the resuscitation fluid dose (R2 = 0.811) and the I/O ratio as well (R2 = 0.86), crossing unity at 2.85 mL/kg/%TBSA. A ratio > 1 signals high evaporative drive and/or possible under-resuscitation; a ratio < 1 alerts to fluid creep before significant weight gain. Conclusions: The TEWL/edema ratio is the first physiology-grounded, easily calculable resuscitation endpoint that complements urine output by providing insight into whether administered fluid is lost as obligatory evaporation or sequestered as edema. Routine estimation of expected TEWL and early monitoring of the TEWL/edema ratio may help guide goal-directed burn resuscitation, especially when early excision is delayed or impossible. Given the substantial inter-individual variability, the ratio derived from aggregate data should not be interpreted as a patient-specific predictor.

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