Page 81 - JSOM Fall 2019

FIGURE 3 Results from the taste test. The five oral rehydration the volume delivery of fluids via an NG tube may be limited
solutions are statistically binned in different groups, which are by gastric emptying and reduced intestinal motility. As men-
denoted by the letters above each bar (i.e., for saltiness, Gatorade, tioned earlier, there may be other solutions that prove to be
Drip-Drop, and CeraSport are in one bin and CeraLyte 70 and ORS
are in the other bin). Both Gatorade and Drip Drop consitently more effective at lower volumes. For example, the CeraLyte
ranked higher than WHO-ORS and CeraLyte 70 in each category 70 solution examined herein uses rice-based carbohydrates as
(p < .0001) for both flavor and consumer profiles. CeraSport was opposed to glucose. In theory, this may facilitate absorption
rated in the middle, and often higher than WHO-ORS and CeraLyte through the sodium-glucose transporter along the length of
70 (p < .001) for every category except for viscosity (CeraSport the small intestine as opposed to the most proximal portion of
versus CeraLyte 70, p = .2453).
the duodenum. Additionally, the absorptive capacities of the
large intestine may also be leveraged with additives such as
amylase-resistant starches. We believe enteral fluids should
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be viewed as an untapped potential for resuscitation strategies
in the resource-limited or austere environment and for reduc-
ing IV fluid requirements.

One final consideration on palatability is the environmental
exposure to the packets and reconstituted solutions. PFC sce-
narios that preclude IV fluid delivery will likely also not have
refrigeration for ORS fluid. While these sachets of ORS pow-
der are very stable in extreme (i.e., hot/cold) environments, in
the present study they were given at room temperature, but
in future combat scenarios their administration may only be
influenced by their solubility at encountered temperatures.
In this regard, previous taste tests of ORS have shown that
subjects have a preference for solutions when they are cold
versus the same solution given at room temperature (G.C.
Kramer, unpublished observations). While, again, this may be
circumvented by the use of an NG tube, both of these delivery
methods may increase the incidence of vomiting seen in burn
patients receiving enteral fluids

Published Guidelines for Low-Resource Scenarios
Despite the lack of evidence comparing different volumes
or types of enteral fluids, there are published guidelines for
their use in austere environments or in prolonged field care
scenarios. 41–46 Also, considering the recent substantial IV fluid
shortage due to the destruction of Puerto Rican manufacturing
plants by Hurricane Maria, it is prudent to develop enteral
strategies for resuscitation. In response to this shortage, oral
Specifically, Gatorade is likely the highest scored in the cur- resuscitation guidelines were recently published as an alterna-
rent study because of its sugar content, which also makes it tive in cases of mild to moderate dehydration recommending
hyperosmotic (Figure 2). The high sugar and sodium content sips every 3 minutes. While this approach is likely insuffi-
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increases hyperosmolarity and hurts the efficiency and efficacy cient in instances of severe dehydration (as in burns), there is
of this solution, which may only be exacerbated in the insu- precedent for oral resuscitation. Amazingly, neither the anes-
lin-resistant burn patient. For this reason, other solutions that thesia handbook for the International Committee of the Red
are currently commercially available (e.g., Drip-Drop) may Cross nor the resuscitation first aid guidelines for the Inter-
optimize palatability and efficacy. national Federation of Red Cross mention the use of enteral
fluids in burn injuries. With this in mind, however, the follow-
While osmolarity on extreme ends of the spectrum may be ing section concentrates on burn field guidelines published for
recognizable, it is worth noting that optimal osmolarity for resource-poor settings.
burn injury has not been studied in detail. Indeed, the solu-
tions examined above have had much more extensive study in The recent PFC fluid working group suggested that oral fluids
other conditions (dehydration due to heat, exercise, dysentery, are feasible in patients with 15% to 40% TBSA burns, which
cholera, etc.). The WHO-ORS used in this study is the more may represent a critical burn size in which intervention would
recent version that had osmolarity reduced, which is still con- have a clinical benefit. It is noted that reports of the use of
18
troversial even for the use in cholera-mediated diarrhea. Dif- oral resuscitation have been effective for larger burns. 16,41 Pub-
37
ferent agents such as amino acids and starches that promote lished guidelines in austere environments provide a good over-
absorption in the large intestine have also been recommended view of potential solutions, from those studied in this report,
in this population. 38,39 Although diarrhea is unlikely to be an to chicken broth and apple juice. For volume, the suggestion
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issue in the burn patient, inferences of the best solution are was to take frequent sips with the goal of ingesting roughly 1 to
largely drawn from experiences in other conditions. 2L per hour, with resumption a few minutes after vomiting if
44
it occurs. Interestingly, this study also suggests that overresus-
Additionally, palatability would not be an issue in the case citation as seen with IV resuscitation is unlikely to happen, fur-
where a nasogastric (NG) tube is placed. On the other hand, ther promoting the need for a randomized, multicenter study.

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