Oral Rehydration Therapy and Feeding Replaces Total Parenteral Nutrition: A Clinical Vignette
Scott Mitchell Wright and Muhammad Jawad Noon are Co-first authors.
Clinical Vignettes Oral Rehydration Therapy and Feeding Replaces Total Parenteral Nutrition: A Clinical Vignette
Scott Mitchell Wright 0 2 3
Muhammad Jawad Noon 0 2
William Bates Greenough III 0 2 3
0 Ceralyte 70 Sodium Potassium Chloride Citrate Osmolarity Rice digest Normal isotonic saline Sodium Chloride Osmolarity TPN TPN Calories Amino acid solution Fat emulsion
1 Shifa College of Medicine , Islamabad , Pakistan
2 Table 1 Composition of Ceralyte 70, Isotonic IV Saline and TPN
3 Johns Hopkins University School of Medicine , Baltimore, MD , USA
A 27-year-old patient with spina bifida and a high output loss of water and electrolytes from her ileostomy was successfully liberated from dependency on total parenteral nutrition and intravenous fluid and electrolyte replacement by the use of a rice-based oral rehydration therapy (ORT). This allowed her to return home to the care of her mother. We suggest that ORT can be effective in the context of modern high-technology settings, as well as in resource-poor situations.
Total parenteral nutrition (TPN), introduced in the 1960s,
made it possible to replace intestinal water and electrolyte
losses and provide nutrients in patients with short bowel
syndromes (SBS), as well as diarrheal diseases. There are,
however, serious complications of TPN, including central line
infections, which can be associated with sepsis, and increased
hepatic enzymes.1 In addition to the nutrients provided by
TPN, supplemental intravenous fluids and electrolytes are
often needed to replace intestinal fluid losses and recurrent
volume depletion. When an alternative to supplemental
intravenous replacement is necessary, oral rehydration therapy
(ORT) may be substituted. It can replace both water and
electrolyte losses more safely and conveniently in patients
with short bowel syndromes.2 At present, ORT is being
underutilized in our modern high technology medicine
delivery systems. We report a case of a young woman with an
ileostomy who was able to transition off TPN to a combination
of enteral feeding and a rice hydrolysate oral rehydration
therapy (ORT) (Ceralyte)3 as a less troublesome, safer, and
inexpensive alternative to intravenous therapies, allowing her
to go home in the care of her mother.
Osmolite and Perative formulations can be found in product information
manual of Abbott Nutrition or online
< 220 mosm/L
40 g/L (160 k cal)
3000 ml/24 hr.
*An extra 500 ml of Ceralyte® was given to the patient on 16 September 2010 as she seemed dehydrated. During this period, the patient was also
getting 1000 ml of water daily on average
† During this period, the patient was getting 1000 ml of water daily on average
‡ IVF: Intravenous Fluid (Isotonic saline)
§ Perative® is a form of enteral nutrition
We attempted to reduce ileal losses using octreotide, but it
was not effective. We did not use anti-motility medications, as
they are marginally useful in enhancing absorption of water and
electrolytes.4 Feeding via the gastrostomy tube was begun and
did not reduce salt and water losses, so it was stopped. There
was no evidence of recurrence of C. difficile in her remaining
ileum. She was weaned from the ventilator over a period of
2 weeks, and we initiated a rice-digest–based oral rehydration
solution (Ceralyte® 70) (Table 1) through her gastrostomy tube
to replace volume losses. ORT relies on the glucose-sodium
carrier mediated transport system of the small intestine,4 and
allows effective absorption of water and electrolytes.
Ricebased ORT is more effective than glucose based formulations;
it diminishes salt and water losses as well as replaces them. The
ORT allowed us to discontinue supplemental intravenous saline.
We then transitioned from TPN to Osmolite® 1 Cal through
her gastrostomy tube. Seventy-two days after admission, she
was discharged home in the care of her mother with no
intravenous fluid requirements or intravenous lines. Her sacral
wounds were healing, and her mother was taught that the
amount of ORT required was best judged by her urine output,
which was maintained at between 1 and 2 l daily. In this
patient’s case, the ORT (Ceralyte® 70) could be administered
via her gastrostomy tube.
Table 2 shows the daily intake and ileostomy output of our
patient. Introduction of ORT was associated with a decrease in
ostomy output, even though her daily intake initially increased
during the transition phase (30 August 2010 to 9 September
2010). The output then remained low during the subsequent
follow-up periods. In addition to ORT and enteral feeding, she
received 1000 ml of water daily while off the TPN to prevent
hypernatremia, and this also served the function of flushing the
gastrostomy tube to prevent clogging.
Oral Rehydration Therapy (ORT) is based on the coupled
transport of sodium and glucose.5 Even in high output
diarrheas such as cholera, a positive fluid and electrolyte
absorption can be achieved. In conscious patients who are able to
drink, ORT is a safe substitute for an intravenous infusion,
making it possible to avoid the complications of central lines
with associated hazards of insertion and
central-line–associated bloodstream infections (CLABSI). About ORT, The Lancet
mentions, ‘the discovery that sodium transport and glucose
transport are coupled in the small intestine, so that glucose
accelerates absorption of solute and water, was potentially the
most important medical advance this century.’6 During an
epidemic of cholera during an exodus of refugees from
Bangladesh to India, it was demonstrated that mortality rate due to
dehydration was 3.6 % in the refugee camps that relied on
ORT as compared to between 30 and 40 % where no such
replacement was available.7 Moreover, a randomized
controlled trial at University of Pennsylvania comparing ORT
with intravenous rehydration in moderately dehydrated
children found no difference between the rehydration strategies.8
Our case demonstrates that ORT can effectively replace water
and electrolytes in patients with high output ostomy losses,
just as it is known to do in those with diarrhea.
Long-term TPN leads to increased risk of pancreatic atrophy,
gall stones, impaired renal and hepatic function, and is linked
with overfeeding, hyperglycemia, sepsis, and intestinal atrophy.1
ORT, on the other hand, can avoid the pain of needles, the
complications of central line insertion and infections, and is less
expensive. It can be administered by family members at home
without any technical assistance. It is estimated that about $1
billon per annum can saved by implementation of ORT if it were
used in the US healthcare system.9 Furthermore, feeding or use of
complex-carbohydrate–based ORT can reduce intestinal fluid
losses, thereby diminishing the volume that is required to be
replaced.10,11 In our patient, the ileal losses were higher while
the patient was solely on TPN, and diminished as ORT and tube
feedings were started (Table 2). This observation corresponds
with prior observations noted in studies that showed decreased
stool output with the use of digestible-polymer–based ORT in
people suffering from diarrheal diseases.12 However, there are
limitations to drawing conclusions from a single clinical vignette.
It is possible that the underlying cause for the high ostomy output
might have resolved spontaneously. The fact that this coincided
with the introduction of ORT makes this unlikely. Therefore,
there is a need to conduct well-designed prospective studies with
an adequate sample size to test the benefits of ORT in patients
with high ostomy losses. We also acknowledge that some patients
with severe vomiting and nausea might not be able to tolerate
ORT, and aspiration can be a hazard.
Since WHO recommended ORT as a first-line therapy for
mild to moderate dehydration,13 it has been accepted and
implemented globally. However, ORT as a substitute for
intravenous water and electrolyte therapy has been neglected in
high technology healthcare delivery settings. Literature from
North America rarely focuses on the use of ORT, and this
therapy is principally restricted to childhood diarrheal
illnesses. Recently, ORT has been shown to have successfully
replenished fluid/electrolyte losses in two groups of adult
patients. Milner et al. demonstrated that in patients with
moderate burn injuries, introduction of ORT substantially reduced
the requirement of continuing IV fluid therapy.14 Moreover, a
case series showed that ORT was associated with early
discontinuation of TPN and improved fluid absorption in patients
with short bowel syndrome.15 With the emergence of
antibiotic resistant organisms, we are now increasingly aware of
complications of central venous lines, namely infections or
BCLABSIs.^ Further, the cost of hospital admissions or
readmissions for Bdehydration^ or volume depletion is
substantial. For these reasons, it would be wise to educate health
workers and caregivers about how to use ORT as a safe early
intervention that could reduce, if not avert, needless
emergency room visits and hospital admissions.
Our case demonstrates that a transition from hospital to
home and physicians/nurses to family/ caregivers can be
accomplished with the substitution of ORT and feeding for TPN
and intravenous therapies.
Acknowledgements: We thank Angela Kinn and Richard Marcinko
PACs for their excellent patient care, and Shannon Meise for her
assistance with manuscript preparation.
Conflict of Interest: W.B. Greenough, III, MD is a shareholder and
scientific advisor for Cera Products, Inc., which produces Ceralyte®. All
other authors declare that they do not have a conflict of interest.
Ethics Statement: ORT is a safer, less costly method for hydration
that in many cases can substitute for intravenous fluid therapy.
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