Diarrhea In Severely Burned

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Diarrhea In Severely Burned

• Children
• K. Thakkar, C.L. Kien, J.I. Rosenblatt, D.N.
  Herndon
• Shriners Burns Hospital

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Background

• Diarrhea common in burned children
• Complicates Skin wound Care
• Nursing care more difficult

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Complications

• Electrolyte disturbances
• Inadequate nutrition
• Bacterial Translocation
• Gut Injury
• Wound Contamination

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Causes of Diarrhea

• Hyperdynamic state with stress response factors
• Altered Bacterial colonization of gut
• Secretory factors cytokine, bile salt-mediated
  colonic secretion
• High Feeding Volumes
• High enteral carbohydrate loads leading to
  malabsorption and osmotic diarrhea

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Enteral Nutrition

• 82 Carbohydrates
• Glucose polymers
• Meet energy requirements
• Protein Sparing effects
• Limit fat intake

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Carbohydrate Malabsorption

• Unabsorbed Carbs from small bowel broken down by
  colonic bacteria
• Only small amounts of simple sugars are not
  absorbed in small intestine
• Malabsorption a combination of small intestine
  carbohydrate maldigestion and failure of colonic
  salvage

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Breath Hydrogen

• Measure of fermentation
• Products methane, hydrogen, carbon dioxide
• Hydrogen passes into circulation and is exhaled
• Direct relationship between the hydrogen
  concentration in expired breath and the amount of
  unabsorbed carbohydrate in the colon

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Breath Hydrogen

• Expired air is collected into a sealed container
• H2 content of each air sample is determined by
  gas chromatography
• Expressed as a ratio to CO2 concentration
• Normal breath hydrogen level in healthy, fasting
  children is 7 5ppm

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Methods

• Measure on weekly basis for 4 weeks post burn
• Total carbohydrate intake
• Total enteral intake
• Total stool output
• Breath Hydrogen concentration

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Inclusion Criteria

• Burns totaling gt40 total body surface area
• Ages newborn to 18 years
• Admitted to Shriners Hospital within 72 hrs
  post-burn

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Exclusion Criteria

• Children with full thickness burns less than 40
  BSA
• Children unable to exhale into a breathing bag
  and do not have either a endotracheal tube or a
  tracheostomy

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Stool Volume vs Fluid Intake
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Results

• Diarrhea (stool volume gt 10 ml/kg/day) in 18
  patients
• BH2 concentration was 5.53.5 at maximal
  carbohydrate intake
• No correlation between stool output and
  carbohydrate intake
• No correlation between stool output and breath
  hydrogen

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Conclusions

• Children with severe burns have diarrhea
• Breath hydrogen was detectable in some patients,
  suggesting carbohydrate malabsorption
• No clear relationship between stool output and
  carbohydrate intake or breath hydrogen

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Conclusions

• High fluid intakes do not appear to exacerbate
  diarrhea
• Diarrhea in burn patients due primarily to
  factors other than carbohydrate malabsorption
• These data do not support altering enteral
  feeding because of watery diarrhea

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Acknowledgements

• Respiratory Therapy staff at Shriners for
  assistance with breath sample collection
• Wes Benjamin and Sylvia Ojeda for collection of
  clinical data
• Randy Warnken for dietary data
• Nursing Service second floor of Shriners Hospital

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