diarrhea in severely burned
TRANSCRIPT
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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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