Diarrhea in tube-fed burn patients: incidence, etiology, nutritional impact, and prevention

The hypermetabolic state observed in thermally injured patients warrants aggressive nutritional management. Enteral support is the preferred route of nutrient delivery, however diarrhea is reported to be a persistent complication of continuous nasogastric or nasoduodenal hyperalimentation. Diarrhea adds to problems in patient care, disturbs fluid and electrolyte balance, and worsens nutritional status. There has been the impression that tube feeding hyperosmolality, antibiotics, and low serum albumin induce diarrhea. However, in view of the sparsity of published work, a prospective study was undertaken to determine the incidence of diarrhea and to define factors associated with its cause. Of the 50 patients studied, 16 (32%) developed diarrhea. Stool cultures were negative for pathogenic organisms. Although the risk of diarrhea was associated with antibiotics (p less than 0.005), several nutrients also had an impact. Results demonstrated a significant relationship between dietary lipid content (p less than 0.05) or vitamin A intake (p less than 0.001) and diarrhea. Implementation of tube feeding within 48 hrs postburn was also associated with a decreased incidence of diarrhea (p less than 0.001). This paper describes a modular tube feeding program in which diarrheal frequency is lessened (p less than 0.0001). Surprisingly, tube feeding osmolality, drugs used to prevent stress ulcers, or hypoalbuminemia did not have an adverse effect on intestinal absorption. The cause of diarrhea in burn patients is obviously multifactorial. It is concluded that a low fat (less than 20% of caloric intake), vitamin A enriched (greater than 10,000 IU/day), early enteral support program maximizes conditions which promote tube feeding tolerance while minimizing nutrient malabsorption during the nutritional rehabilitation of thermal injury.