Gastrointestinal fluid resuscitation of thermally injured patients.

A seminal advance in the care of thermally injured patients was the recognition of the large volumes of fluid required during resuscitation and the relationship of these volumes to burn size and body weight. This discovery resulted in the virtual elimination of acute renal failure as a consequence of burn shock. Today, the established standard of care focuses on the intravenous route for fluid resuscitation, and time to intravenous access was an independent predictor of mortality in a study of children with massive burns by Wolf et al. Historically, however, several other methods have been used for delivery of fluids to patients with burn shock, including oral, rectal, and subdermal routes. Several factors led to the preferential use of the intravenous route. It enables the immediate delivery of known quantities of fluid and allows the rapid correction of circulating volume deficits. By contrast, the other routes provide uncertain amounts of fluid at more gradual rates, and vomiting may complicate oral fluid intake. Finally, plasma or albumin solutions can only be given intravenously. Despite the advantages of intravenous therapy, an increasing focus on preparedness for mass-casualty and austere scenarios has caused us to reexamine the utility of oral, intestinal, and rectal resuscitation of thermally injured patients. The detonation of a single nuclear weapon in an urban area would likely generate a large number of thermally injured survivors. The likelihood of there being survivors with burns increases with increasing weapon yield, thus, “burn injury is the most difficult problem to be faced by the military medical community in a nuclear conflict.” During the first part of Operation Iraqi Freedom in 2003, the U.S. Army Institute of Surgical Research in collaboration with the American Burn Association and the National Disaster Medical System conducted a daily inventory of burn beds in the United States. This research demonstrated that the number of available burn beds in the United States would be insufficient to handle the number of casualties that would be produced by a single nuclear weapon. Even a conventional disaster can generate enough burn casualties to overwhelm the medical system. We would speculate that such might have been the case had the World Trade Center towers not collapsed on September 11, 2001. Under circumstances such as these, alternatives to physician-directed, intensive care unitbased, intravenous fluid resuscitation of burn patients will be needed. Concerns regarding potential combat casualties caused by nuclear weapons in the Korean War motivated an examination of oral fluids for burn shock by the 1950 Surgery Study Section of the National Institutes of Health (NIH). Although recognizing the need for further research, the NIH concluded “that the use of oral saline solution be adopted as standard procedure in the treatment of shock due to burns and other serious injuries in the event of large-scale civilian catastrophe.” Fifty-six years after the NIH report, significant gaps remain in our knowledge about the ability of the gastrointestinal tract to absorb sufficient quantities of fluid during burn shock. In addition, Special Operations medics operating under austere conditions may not have access to sufficient volumes of sterile intravenous fluids to permit From the *U.S. Army Institute of Surgical Research, Fort Sam Houston, Texas; and †Resuscitation Research Laboratory, Department of Anesthesiology, University of Texas Medical Branch, Galveston, Texas. Address correspondence to COL Lee Cancio, U.S. Army Institute of Surgical Research, 3400 Rawley E. Chambers Avenue, Fort Sam Houston, Texas 78234-6315. Supported in part by the Combat Casualty Care research program of the U.S. Army Medical Research and Development Command, Fort Detrick, Maryland, and by the Department of the Navy, Office of Naval Research (N00014-03-1-0363 and N00014-06-1-0300) and Shriners Hospitals for Children (8830). The opinions or assertions contained herein are the private views of the authors and are not to be construed as official or as representing the views of the Department of the Army, the Department of the Navy, or the Department of Defense. Copyright © 2006 by the American Burn Association. 1559-047X/2006