Page 78 - JSOM Fall 2019

Operational Advantages of Enteral Resuscitation
Following Burn Injury in Resource-Poor Environments

Palatability of Commercially Available Solutions

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David M. Burmeister, PhD *; SPC Joshua S. Little ; Belinda I. Gómez, PhD ;
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COL Jennifer Gurney, MD ; Tony Chao, PhD ; Leopoldo C. Cancio, MD ;
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George C. Kramer, PhD ; Michael A. Dubick, PhD 8
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ABSTRACT
Background: In recent combat operations, 5% to 15% of ca- Introduction
sualties sustained thermal injuries, which require resource-in-
tensive therapies. During prolonged field care or when caring Burn injury in conventional warfare generally accounts for 5%
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for patients in a multidomain battlefield, delayed transport to 15% of military casualties. Thermal injuries lead to hypo-
will complicate the challenges that already exist in the burn volemia, shock, systemic inflammation, and organ dysfunction
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population. A lack of resources and/or vascular access in the and, without early intervention, can even lead to death. Com-
future operating environment may benefit from alternative re- pared with civilian patients, combat casualties with burns are
suscitation strategies. The objectives of the current report are characterized by a higher percentage of full-thickness burns
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1) to briefly review actual and potential advantages/caveats and a higher incidence of inhalation injury. The extent of
of resuscitation with enteral fluids and 2) to present new data total body surface area (TBSA) burned influences the systemic
on palatability of oral rehydration solutions. Methods: A re- inflammatory reaction as well as burn wound healing which
view of the literature and published guidelines are reported. represent important predictors of patient survival. Among the
In addition, enlisted US military active duty Servicemembers side-effects associated with burns, reduced plasma volume, tis-
(N = 40) were asked to taste/rank five different oral rehydra- sue perfusion, and resultant ischemia can lead to multiorgan
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tion solutions on several parameters. Results and Conclusions: dysfunction (MOD), which is often lethal.
There are several operational advantages of using enteral flu-
ids including ease of administration, no specialized equipment To treat burn shock–related hypovolemia and MOD, early and
needed, and the use of lightweight sachets that are easily recon- aggressive intravenous (IV) fluid resuscitation has drastically
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stituted/administered. Limited clinical data along with slightly improved outcomes during the past several decades. De-
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more extensive preclinical studies have prompted published spite recommendations from the American Burn Association,
guidelines for austere conditions to indicate consideration of there is significant variability in how patients are resuscitated.
enteral resuscitation for burns. Gatorade and Drip-Drop However, there is clear consensus that IV resuscitation should
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were the overall preferred rehydration solutions based on be initiated early, which may prove difficult in resource-poor
palatability, with the latter potentially more appropriate for settings.
resuscitation. Taken together, enteral resuscitation may confer
several advantages over intravenous fluids for burn resusci- According to the North Atlantic Treaty Organization (NATO),
tation under resource-poor scenarios. Future research needs prolonged field care (PFC) is defined as field medical care
to identify what solutions and volumes are optimal for use in applied beyond “doctrinal planning time-lines” by a NATO
thermally injured casualties. Special Operations combat medic in order to decrease patient
mortality and morbidity. By definition, PFC uses limited re-
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sources and is likely to become a more frequent occurrence as
Keywords: burns; prolonged field care; resuscitation; enteral a result of future conflicts in multidomain battlespaces and
fluids; rehydration solutions
dense urban areas. From a logistical standpoint, both vascular
* Address correspondence to US Army Institute of Surgical Research, 3650 Chambers Pass, JBSA Fort Sam Houston, TX 78234 or David.m
.burmeister3.civ@mail.mil
1 Dr Burmeister is a research physiologist for the United States Army Institute of Surgical Research, JBSA Fort Sam Houston, TX, and focuses on
burn resuscitation strategies. SPC Little is a medical laboratory specialist in the US Army, where he aids in research for prolonged field care. Dr
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Gomez is a staff scientist at the US Army Institute of Surgical Research and is interested in enteral resuscitation. COL Gurney, MC, USA, is a gen-
eral trauma and burn surgeon and currently works as the chief of Trauma Systems Development, Joint Trauma System, and the deputy director of
the Burn Center in San Antonio, TX. She has multiple deployments to Iraq and Afghanistan as part of Combat Support Hospitals and Forward
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Surgical Teams. Dr Chao is a postdoctoral fellow for the US Army Institute of Surgical Research interested in the metabolic dysregulation of
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severe burn trauma and therapeutic strategies to mitigate hypermetabolic stress. COL (Ret) Cancio, MC, USA, is the director of the US Army
Burn Center. He deployed as 504 Parachute Infantry Regiment Surgeon, 82d Airborne Division, Operation Just Cause and Desert Storm; with
SOCCENT and 86th Combat Support Hospital during Operation Iraqi Freedom; and with a Forward Surgical Team during Operation Enduring
Freedom. Dr Kramer is a full professor at the University of Texas Medical Branch Department of Anesthesiology. He serves as the director of
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the Resuscitation Research Lab, and his research interests primarily involve the study of perioperative fluid therapy and their application to the
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resuscitation of critically injured patients. Dr Dubick is a resuscitation researcher and the manager of the Damage Control Resuscitation task
area at the United States Army Institute of Surgical Research.
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