Annals of the MBC - vol, 4 - n° 1 -
ORAL REHYDRATION THERAPY IN MODERATELY BURNED
Plastic Surgery, Faculty of Medicine, Assiut University, Egypt
The resuscitation of children with more than 10% 13SA bum requires the administration
of fluids containing salts and water during the first 48 h. The magic effect of the oral
rehydration salt known as "Rehydran-n" in the treatment of children suffering
from diarrhoea suggested the idea of trying it in the resuscitation of moderately burned
children. Children with burns from 10% to 20% 13SA were chosen for the study. Twenty cases
received oral rehydration solution according to a special protocol and 20 cases were
resuscitated by the intravenous route using the Parkland formula as a control group.
Haematocrit, Hb%, serum Na and K were measured, in addition to the assessment of the
clinical picture and determination of the urine vol/h to evaluate the efficiency of oral
rehydration therapy in resuscitation. The results were highly encouraging.
The importance of hypovolaemia as a
cause of death and of morbidity in bums is widely understood, and of the adequate
replacement of lost water, electrolytes and colloid accounts, to an important degree, for
the reduction in mortality from bums. The ultimate effectiveness of resuscitation is
reflected in early mortality (first 7 days) (Baxter, 1978).
The intravenous administration of fluid is generally unnecessary for children with bums in
less than 10% BSA. Even in young patients, however, urine output and vital signs should be
monitored and fluids given orally, with care being taken to prevent gastric dilatation and
aspiration if ileus supervenes (Bruitt, 1978).
The frequent occurrence of ileus in patients with more extensive bums precludes oral
resuscitation, and intravenous fluids will be required.
Children with bums in more than 10% BSA will become hypovolaemic without fluid
resuscitation. In our Burn Unit children with bums represent more than 50% of the
in-patients. About 40% of these burned children have a bum size ranging from 10% to 20%
The aim of this study is to evaluate the efficiency of the oral rehydration salt
"Rehydran-n" in the resuscitation of this group of moderately burned children,
considering its excellent success in the treatment of children suffering from diarrhoea.
Materials and methods
This study was carried out in 40
burned children admitted to the Bum Unit of Assiut University Hospital during the period
from July 1989 to January 1990. Their bums ranged from 10% to 20% BSA. All these children
received the general care for bum patients according to the protocol of treatment in our
Resuscitation of these burned children was either by oral rehydration therapy or by
intravenous fluid therapy. The choice of either form of resuscitation was randomly made,
one patient receiving oral fluid, the next intravenous fluid, and so on.
The first group included 20 children with burns. Their ages ranged from 4 months to 10
years. I I were males and 9 were females, and the mean extent of their bums was 14.2 +/-
2.8% BSA. The cause of the bum was flames in I I children and scalds in 9 (Tab. 1).
This group of patients was resuscitated by the oral route using the oral rehydration salt
(ORS) known as "Rehydran-n" (Cid) (Tab. 2). Assuming that orally given fluids
will be completely absorbed by the GIT and that the amount of fluids required for
resuscitation will depend on the weight of the patient and the extent of the bum, the
fluids needed for the first 24 hours should be in the range of- 4 ml/% BBSA/kg
Each packet of the ORS must be dissolved in 200 cc of water. We can calculate the number
of packets by dividing the total amount of fluids by 200, half the amount of solution to
be given in the first 8 hours and the other half during the next 16 hours.
This fluid will be given by the child's mother under supervision of the nurse and the
Resident of the Bum Unit, using a teaspoon, plastic dropper or a 5 ml plastic syringe.
The rate of giving the solution will depend on the calculated amount of fluids, but is
about 5 ml every 2 to 5 minutes. This solution is also given on the second or even the
third post-bum day, but in smaller amounts, in addition to other nutritional materials
according to the child's needs.
The second group included 20 children with bums considered as the control group. Their
ages ranged from 1.5 to 12 years. 12 were males and 8 were females.
The cause of bum was flames in 10 patients and scalds in the remaining 10. The patients in
this group were resuscitated by intravenous fluid therapy using the Parkland formula
(Baxter, 1981) as a guideline.
All the patients under study were monitored for vital signs and urine output per h. Blood
samples were taken on day 1 and 5 to evaluate the efficacy of resuscitation, by
determination of serum Na and K, percentage of haemoglobin and haematocrit values.
Comparing the mean serum Na levels in
the two groups (Tab. 3), it was found that the values were significantly below average in
both groups (p<0,05) on day I and in spite of its increase on day 5, it was still below
the normal levels and also below the mean serum Na level of normal children in the Assiut
On the other hand the mean serum K level was within normal limits; it is of interest that
on day 5, the mean level decreased, but was still within normal values (Tab. 3).
Regarding the haernatocrit values and Hb% a decrease in both levels occurred on day 5 in
the Ist group, while there were no changes in the values of the 2nd group (Tab. 3).
The urine output during the first 24 h was adequate in both groups. It ranged from 0.8 to
2.5 ml/h in the I st group, with a mean of (1.6 +/- 0.7) (Tab. 1).
There was no case of mortality among the patients in the I st group, while in the 2nd
group one male child with a flame burn in the face and front of the chest, in about 20%
BSA, aged 1.5 years, died (mortality rate 5%). Death occurred on the 6th day after a
severe attack of diarrhoea with rapid deterioration and failure of all resuscitative
The adequacy of resuscitation is most
readily judged by frequent assessment of the patient's general condition, hourly
measurement of vital signs and measurement of urinary output per h following placement of
an indwelling catheter (Bruitt, 1978).
Richard (1986) stated that children with less than 20% BSA bum can be resuscitated by
maintaining adequate oral hydration, using a solution containing sodium chloride 4 gm,
sodium bicarbonate 1.5 gm and orange squash to taste in each litre.
In our trial of giving the ORS "Rehydran-n" for resuscitation of children with
burns between 10% to 20% BSA, it was found that the method of giving this oral, solution
was very simple and most of our patients' mothers were familiar with and well-trained in
using "Rehydran-n". This may be attributed to the television programmes directed
at treatment of summer diarrhoea.
In spite of the survival of all our patients receiving oral rehydration therapy, it was
found that the mean serum Na level was significantly below normal (p<0.05), which may
be attributed to low sodium in the solution. The same low Na level was also noticed in the
control group resuscitated by intravenous lactated Ringer's solution, which is a hypotonic
solution (Na content 130 mEq/1.) To overcome this problem, Monallo (1984) suggested
restoring the water/salt balance by infusing saline solutions of varying sodium content.
|I oral fluid
||4 m - 10 yr
||0.8 - 2.5 ml/h
||(1.6 +/- 0.7)
||1.5 - 12 yr
||1 - 2.5 ml/h
||(1.8 +/- 0.7)
Tab. 1 Clinical
data of burned children
|The oral rehydration salts used in Egypt
follow the standard WHO formula. 5.5 g packets which must be dissolved in 200 cc of water
contain the following:
|In mEq, the basic formula for ORS is:
mEq per 1
|Tab. 2 Rehydran-n(cid)
Baxter (1978) reported that hyponatraernia
is the commonest electrolyte abnormality encountered between day 3 and day 7 post-bum, and
he attributed this hyponatramia to the overestimation of water requirements.
Moyer et al. (1965) reported that following resuscitation hyponatraernia can occur if
evaporative water loss is abruptly reduced by the application of occlusive or biological
dressing, He therefore recommended that patients with bums in less than 50% BSA be given
10 gin of sodium chloride and 30 to 50 ml of molar sodium lactate to replace the sodium
leeched into the dressings.
The amount of sodium administered in the various IV formulae is approximately the same,
i.e. about 0.4 - 0.6 mEq/kg/bum percentage (Magliacani et al., 1984). The Na content in
"Rehydran-n" is 0.09 mEq/ml. When the patient receives 4 ml/kg/% bum, the sodium
content will be 0.36 mEq/kg/bum percentage, which is less than the average amount in the
We advise the use of a more concentrated salt solution in a later study; this can be
achieved by dissolving the packet in 150 ml rather than 200 ml of water, achieving a
sodium intake of 0.48 mEq/kg/bum percentage.
In conclusion, we can say that oral rehydration therapy was used with encouraging results
in the resuscitation of moderately burned children with the following advantages:
simplicity of use, low cost, possibility of use as a first-aid treatment until the patient
arrives at a hospital, no risk of fluid overload, and the avoidance of all the
difficulties and complications of intravenous infusions.
|Differences from our normal Na level (P) * 0.05
A mest for paired observations was used.
NB: The mean serum Na for normal children of a comparable age group was
132.8 +/- 8.2 inEq/1.
Tab. 3 Laboratory
data of the burned children
RÉSUMÉ. La réanimation
des enfants avec une surface corporelle brulée supérieure á 10% requiert pendant les
premiéres 48 heures l'administration de liquides qui contiennent des sels et de l'eau.
Les effets magiques de "Rehydran-n", un sel pour la réhydratation orale, dans
le traitement des enfants diarrhéiques, ont poussé les Auteurs á Vutiliser dans la
réanimation des enfants modérément brúlés. lls ont choisi pour l'étude 40 enfants
avec une surface brúlée de 10 á 20%. Vingt de ces enfants ont été traités avec la
solution de réhydratation orale selon un protocole particulier et les autres, comme
groupe de contróle, avec l'administration ¡.v. de la formule de Park1and. Pour évaluer
Pefficacité de cette thérapie de réhydratation orale, les Auteurs ont mesuré
Mérnatocrite, la natrémie et la kaliémie, et pareillement i1s ont observé le tableau
clinique général et déterminé la diurése (vol/heure). Le résultats étaient trés
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95: 129, 1984.
- Moyer C., Margraf H., Monafo W: Bum shock and
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Surg., 90: 799-811, 1965.
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special considerations. Clinics in Plastic Surgery, 13 (1), 1986.