Diarrhea in Severely Burned

8/8/2019 Diarrhea in Severely Burned

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ComplicationsComplications

Electrolyte disturbancesElectrolyte disturbances

Inadequate nutritionInadequate nutrition

Bacterial TranslocationBacterial Translocation Gut InjuryGut Injury

Wound ContaminationWound Contamination


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Causes of DiarrheaCauses of Diarrhea

Hyperdynamic state with stress responseHyperdynamic state with stress response

factorsfactors

Altered Bacterial colonization of gutAltered Bacterial colonization of gut Secretory factors: cytokine, bile saltSecretory factors: cytokine, bile salt--

mediated colonic secretionmediated colonic secretion

High Feeding VolumesHigh Feeding Volumes High enteral carbohydrate loads leading toHigh enteral carbohydrate loads leading to

malabsorption and osmotic diarrheamalabsorption and osmotic diarrhea


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Enteral NutritionEnteral Nutrition

82% Carbohydrates82% Carbohydrates

Glucose polymersGlucose polymers

Meet energy requirementsMeet energy requirements Protein Sparing effectsProtein Sparing effects

Limit fat intakeLimit fat intake


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Carbohydrate MalabsorptionCarbohydrate Malabsorption

Unabsorbed Carbs from small bowelUnabsorbed Carbs from small bowel

broken down by colonic bacteriabroken down by colonic bacteria

Only small amounts of simple sugars areOnly small amounts of simple sugars arenot absorbed in small intestinenot absorbed in small intestine

Malabsorption a combination of smallMalabsorption a combination of small

intestine carbohydrate maldigestion andintestine carbohydrate maldigestion and

failure of colonic salvagefailure of colonic salvage


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Breath HydrogenBreath Hydrogen

Measure of fermentationMeasure of fermentation

Products: methane, hydrogen, carbonProducts: methane, hydrogen, carbon

dioxidedioxide Hydrogen passes into circulation and isHydrogen passes into circulation and is

exhaledexhaled

Direct relationship between the hydrogenDirect relationship between the hydrogenconcentration in expired breath and theconcentration in expired breath and the

amount of unabsorbed carbohydrate in theamount of unabsorbed carbohydrate in the

coloncolon


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Breath HydrogenBreath Hydrogen

Expired air is collected into a sealedExpired air is collected into a sealed

containercontainer

HH22 content of each air sample iscontent of each air sample isdetermined by gas chromatographydetermined by gas chromatography

Expressed as a ratio to CO2 concentrationExpressed as a ratio to CO2 concentration

Normal breath hydrogen level in healthy,Normal breath hydrogen level in healthy,fasting children is 7fasting children is 7 5ppm5ppm


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MethodsMethods

Measure on weekly basis for 4 weeks postMeasure on weekly basis for 4 weeks post

burn:burn:

Total carbohydrate intakeTotal carbohydrate intake Total enteral intakeTotal enteral intake

Total stool outputTotal stool output

Breath Hydrogen concentrationBreath Hydrogen concentration


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Inclusion CriteriaInclusion Criteria

Burns totaling >40% total body surfaceBurns totaling >40% total body surface

areaarea

Ages newborn to 18 yearsAges newborn to 18 yearsAdmitted to Shriners Hospital within 72 hrsAdmitted to Shriners Hospital within 72 hrs

postpost--burnburn


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Exclusion CriteriaExclusion Criteria

Children with full thickness burns less thanChildren with full thickness burns less than

40% BSA40% BSA

Children unable to exhale into a breathingChildren unable to exhale into a breathingbag and do not have either abag and do not have either a

endotracheal tube or a tracheostomyendotracheal tube or a tracheostomy


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S t o o l O u t p u t v s . C a r b o h y d r a t e I n t a k e a t T i m e o f M a x i m a l S t o o l

O u t p u t

0

5 0 0

1 0 0 0

1 5 0 0

2 0 0 0

2 5 0 0

3 0 0 0

3 5 0 0

0 2 0 0 4 0 0 6 0 0 8 0 0 1 0 0 0 1 2 0 0 1 4 0 0

C a r b o h y d r a t e I n t a k e ( g / d )

StoolOutput(m

l/d


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Stool Output Vs. Breath H2 Concentration at Time of Maximal Stool Output

0

10

20

30

40

50

60

70

80

0 10 20 30 40 50 60 70 80

Breath H2 Conc. (ppm/% CO2)

StoolOutput(ml/kg/d)


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Stool Volume vs Fluid Intake

FIGURE 1

0

500

1000

1500

2000

2500

3000

3500

0 1000 2000 3000 4000 5000 6000

ENTERAL FLUID INTAKE

STOOLVOLUM


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Net Water Absorption vs. Water Intake

-1000

0

1000

2000

3000

4000

5000

0 1000 2000 3000 4000 5000 6000

Enteral Water Intake (ml/d)

NetWaterAbsorption(ml/d)

r=0.887;

(P


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ResultsResults

Diarrhea (stool volume > 10 ml/kg/day) inDiarrhea (stool volume > 10 ml/kg/day) in

18 patients18 patients

BH2 concentration was5.5

BH2 concentration was5.53

.5

at3.5

atmaximal carbohydrate intakemaximal carbohydrate intake

No correlation between stool output andNo correlation between stool output and

carbohydrate intakecarbohydrate intake

No correlation between stool output andNo correlation between stool output and

breath hydrogenbreath hydrogen


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ConclusionsConclusions

Children with severe burns have diarrheaChildren with severe burns have diarrhea

Breath hydrogen was detectable in someBreath hydrogen was detectable in some

patients, suggesting carbohydratepatients, suggesting carbohydratemalabsorptionmalabsorption

No clear relationship between stool outputNo clear relationship between stool output

and carbohydrate intake or breathand carbohydrate intake or breath

hydrogenhydrogen


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ConclusionsConclusions

High fluid intakes do not appear toHigh fluid intakes do not appear to

exacerbate diarrheaexacerbate diarrhea

Diarrhea in burn patients due primarily toDiarrhea in burn patients due primarily tofactors other than carbohydratefactors other than carbohydrate

malabsorptionmalabsorption

These data do not support altering enteralThese data do not support altering enteral

feeding because of watery diarrheafeeding because of watery diarrhea


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AcknowledgementsAcknowledgements

Respiratory Therapy staff at Shriners forRespiratory Therapy staff at Shriners for

assistance with breath sample collectionassistance with breath sample collection

Wes Benjamin and Sylvia Ojeda forWes Benjamin and Sylvia Ojeda forcollection of clinical datacollection of clinical data

Randy Warnken for dietary dataRandy Warnken for dietary data

Nursing Service second floor of ShrinersNursing Service second floor of ShrinersHospitalHospital


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Documents

Diarrhea in Severely Burned