Page 80 - JSOM Fall 2019

with WHO). Each rehydration solution was prepared ac- the joint International Society for Burn Injury and American
cording to manufacturer’s instructions and presented to the Burn Association survey revealed that greater than 80% of
participants at room temperature. The survey used (Figure 1) respondents indicated oral formulas to be working for burns.
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included questions on saltiness, sweetness, viscosity, and taste. However, this study also revealed a general lack of enthusiasm
Additionally, more subjective measures of palatability were for the use of enteral fluids, as there was a significantly lower
also included, as well as a final ranking of each of the five response rate for questions about oral resuscitation versus the
solutions. other categories.

Statistical Analyses To summarize, preclinical studies of oral resuscitation largely
GraphPad Prism was used for statistical analysis and graphic conclude that the strategy is likely safe and efficacious, but
representation of data. Analysis was completed with a two- protocols need to be optimized and standardized. A seminal
way ANOVA for both the drink characteristics and consum- animal study demonstrated absorbance of greater than 90%
er-based questions. All data are presented as mean ± SEM. of the infused oral rehydration solution (ORS) in a 40% TBSA
Significance was set at p < .05. burn wound pig model. More recently, a similar model was
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used to show efficacy in reversing acute kidney injury. Both
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of these studies used the WHO-ORS, which has been used
Results and Discussion
with great success in underdeveloped nations for the treat-
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Literature Search Results ment of severe dehydration. The ease of use for this solu-
The two searches using key words “oral resuscitation burn” tion resulted in large-scale implementation and has since saved
and “enteral resuscitation burn” resulted in 162 unique pub- thousands of childrens’ lives from afflictions such as cholera.
lications, of which 130 were excluded. For example, articles However, there are many other ORS formulations that are
written in another language (n = 34) were excluded, as were widely available and efficacious, many with additives that
articles that appeared because “burn” was in the author af- may prove beneficial such as pyruvate solutions. 32,33 In fact,
filiation (n = 5) or used “oral” as a method description (n one study showed superiority of pyruvate oral solutions over a
= 3). Many articles were excluded because of irrelevance to citrate-based solution in terms of intestinal blood flow. There
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the topic, which included publications that focused on timing is also a distinct possibility that incorporating pharmacologi-
and volumes of nutrition administration (n = 31), airway man- cal agents (e.g., opiates or cholinomimetics) may also improve
agement (n = 14), conditions other than burns (e.g., Steven the absorption rate of ORS ; however, this needs to be studied
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Johnson syndrome, n = 15), or wound healing (n = 3). Other in further detail.
articles not pertinent to the discussion were reviews that did
not focus on the topic of burn resuscitation (n = 25). Of the 32 Palatability of Resuscitation Fluid
studies selected for inclusion, there was a fairly even distribu- The use of ORS in a conscious patient may have low applica-
tion of preclinical studies (n = 13), clinical studies (n = 8), and tion if the palatability is undesirable. To that end, results of the
review papers focused on austere environments or underdevel- taste test performed in the current study are shown in Figure
oped countries (n = 11). 3. A similar scoring trend was seen for all questions that asked
about flavor (Figure 3A) and consumer variables (Figure 3B).
Clinical evidence focusing on enteral resuscitation was dis- Specifically, Gatorade and Drip-Drop were the highest ranked
cussed as early as 1950, as an National Institutes of Health– rehydration solution across all variables and were consistently
funded study advocated for the use of oral saline as a standard ranked higher than CeraLyte 70 and WHO-ORS (p < .0001).
procedure for the treatment of burn shock. Subsequently, Twenty of the 40 active duty Servicemembers ranked Gato-
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oral fluids were shown to be superior to IV fluids in patients. rade as their favorite, with 16 members preferring Drip-Drop
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Some reports have suggested that burns up to 45% TBSA over the other solutions. No participant ranked these products
may be treated with oral fluids, and there have been calls to as tied. In regard to saltiness, sweetness, viscosity, and overall
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perform a trial of oral fluid resuscitation in larger burns. 22,23 taste, WHO ORS was found to be the lowest ranked, with
Currently, the limited existing clinical evidence has prevented 72.5% of participants rating the salt content in WHO ORS
widespread use of enteral fluids in burn injury, although com- to be highly unpalatable. Gatorade was selected as the overall
plications of this strategy have been minimal. A more recent preferred solution because 60% of participants stated that as
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study provided type 1 evidence comparing enteral resuscita- a consumer they would purchase this solution regularly. Drip-
tion to IV fluids in a randomized, controlled fashion, and Drop was also observed as a solution the participants would
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found enteral fluids to be equally effective for treating acute purchase regularly, with 37.5% of participants claiming they
kidney injury with increased urine output on day 3 in the en- would buy it regularly. While participants determined that
teral fluid group. Still, the authors faced difficulty in the re- both CeraLyte 70 and WHO ORS were not palatable enough
cruitment of subjects for the enteral fluid group, leading to a to be purchased regularly, only 22.5% of participants claimed
small sample size. that they would purchase CeraSport regularly as a consumer
based on taste.
The idea of supplementing IV fluids with oral fluids was
brought up in one study of three burn patients that showed Palatability is a major consideration when employing enteral
a reduction in the requirement of IV fluids by 58%. This fluids, as a rehydration solution will not be effective if not
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study calculated enteral fluids as part of the total fluid volume ingested. While previous studies have examined the incidence
needed in these patients, which is not typical. For example, of vomiting in burn patients to explore what percentage of
while over half of the burn centers queried in the United King- patients would be candidates for enteral resuscitation, stud-
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dom used oral/enteral fluids, only about one-fifth of respon- ies that have explored enteral fluids in patients did not con-
dents thought the approach of oral/enteral fluids to be effective sider vomiting to be contraindicated. 25,26 Moreover, increased
and included them in the volume formula. To the contrary, palatability should not be made at the expense of efficacy.
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78 | JSOM Volume 19, Edition 3 / Fall 2019