Medical Nutrition Therapy for Burns

3n2 –Group 2 November 30,2010

Burns

• Refer to the tissue

injury ,destruction or breakdown,

loss of protoplasmic mass, and

erosion of body reserves caused by:

excessive heat

caustics ( acids, alkalis)

friction

electricity

radiation.

3 Classifications of Burns

1. First degree burn

• Injury involving only the outer epidermis layer

• With simple redness ( erythema) of the affected parts

• Not serious • Patient may go home after first

aid treatment• Resolves in 48-72 hours with

comfort measures.

2. Second degree burn

• The entire epidermis and upper third of the dermis are destroyed

• Vessels leak plasma which lifts off the epidermis thus the appearance of blisters in addition to erythema , it is wet and very painful

• The amount of surface affected is 15% for adults and 10% for children

• Heals within two weeks via repopulation of epithelial cells present in skin appendages and the deep dermis

3. Third degree burn

• The injury extends into the dermis, leaving few viable epidermal cells

• With actual destruction of the skin and underlying tissues causing charring

• Wounds are red with scattered deeper white areas throughout.

• Wounds require months to heal

How to Determine Percentage of Burns

• LUND-BROWDER CHARTRelative Percentage of Body Surface Area Affected by Growth

Age in years 0 1 5 10 15 Adult

A-head (back or front) 9½ 8½ 6½ 5½ 4½ 3½

B-1 thigh (back or front) 2¾ 3¼ 4 4¼ 4½ 4¾

C-1 leg (back or front) 2½ 2½ 2¾ 3 3¼ 3½

Rule of Nines for adults

Pathophysiology of Burns

Effects of Burns

• Loss of skin surface• Loss of enormous fluids, electrolytes, and proteins• Fluid loss because water movers from the burned site to compensate

for the loss, thus reduces blood volume, blood pressure, and urine output

• Energy requirements increase to as much as 100% above resting energy expenditure (REE) depending on extent of burn

• Protein catabolism and increased urinary nitrogen excretion

• Prone to infection• Major burns may develop ileus and are anorexic

Medical Management

Fluid and Electrolyte Repletion

• The first 24 to 48 hours of treatment for thermally injured patient are devoted to fluid and electrolyte replacement

• Most agree that half of the calculated volume for the first 24 hours must be given during the first 8 hours, because this period of greatest intravascular loss.

• The volume of fluid needed is based on the age and weight of patient and extent of burn

• Evaporative water loss can be estimated at 2.0 to 3.1 ml/kg of body weight per 24 hours per percent TBSA ( total body surface area) burn.

• Serum, sodium, osmolar concentrations, and body weight are used to monitor fluid status

• Adequate fluid and electrolytes can maintain circulatory volume and preventing ischemia ( insufficient supply of blood to a specific organ or tissue)

Wound Management

• Depends on depth and extent of burn

• Surgical management promotes early debridgement, excision, and grafting

• Covering wounds may reduce energy expenditure, evaporative heat and nitrogen losses , as well as to prevent infection

Ancillary ( assisting) Measures

• Physical therapy - helps prevent muscle wasting and atrophy

• Warm environment- minimizes heat loss and the expenditure of energy to maintain body temperature

• Thermal blankets, heat lamps, and individual heat

shields

• Minimizing fear and pain medication

• Antacids- given to patients with major burns to

prevent formation of stress-related Curling’s ulcers

in the gastric or duodenal mucosa

Medical Nutrition Therapy

Aims of the Dietary Management for Burned Patients

• to correct fluids and electrolyte imbalance• prevent tissue catabolism and weight loss• achieve and maintain equilibrium especially for

nitrogen, vitamins, and minerals • hasten wound healing and prevent infections

Factors that affect the Dietary Modification

• Depth of thermal injury• Gastrointestinal function• Hypercatabolic state after a serious burn• Feeding should be initiated soon after resuscitation

Early enteral feeding within 4-12 hrs of hospitalization was found to be

successful in the ff:• Decreasing the release of cathecolamines• Decreasing glucagon• Reducing weight loss• Shortening hospital length of stay• Provides immune stimulants and serves as effective

prophylaxis against stress-induced gastropathy and gastrointestinal hemorrhage

1. Energy Requirements

• Vary according to the size of burn ( 1 palm = 1% total body surface)

• Curreri formula ( formula for caloric requirement:

Kcal needed per day= 24 kcal x kg usual body weight + 40 kcal x % TBSA burned ( using a maximum of 50% burn) -------( Krause, 2004)

Kcal needed per day ( adults) = ( 25 kcal) x preborn body weight in kg + ( 40 kcal x % BSA burned) ------( Claudio, 2004)

Kcal needed per day (children) = 30 to 100 kcal [RDA for age] + preborn body weight in kg + ( 40 kcal x % BSA burned) -------( Claudio, 2004)

• Maximum caloric load that the body can handle is approximately 100% above resting metabolic expenditure ( 2X REE)

• Indirect Calorimetry – best method in assessing Energy Expenditure especially obese patients since they have higher risk of wound infection and graft disruption

Ireton Jones Equation:

EEE= 1784 – 11(A) + 5 ( W) + 244 ( G) + 239 ( T) + 804 ( B)

• Where: EEE= Estimated Energy Expenditure ( kcal/day) A= Age

W= Weight ( For obese IBW more than calculated; ABW less than calculated)

G= Gender ( female=0; male =1) T= Diagnosis of Trauma ( absent =0; present =1) B= Diagnosis of burn ( absent=0; present = 1)

• Galveston Formula : ( For different ages)

Energy Requirement= 1800 kcal/m2 + 2200 kcal / m2 of burns

• Mayes and colleagues

Estimated caloric needs for children younger than 3 years of age = 108 + ( 68 x kg weight) + 3.9 x % body surface area burn

2. Energy Sources

• Carbohydrates is an excellent protein sparer• Maximum glucose load of 7 mg/kg/min –

excess will become fatLipogenesis – causes increased oxygen

consumption and carbon dioxide productionHyperglycemia – causes osmotic dieresis

• Omega-3 fatty acids:Improve tube feeding toleranceImproves immune responseInhibit production of prostaglandin E2 and

leukotrienes

• Low fat formula:Less pneumoniaImproved respiratory functionFaster recovery of nutritional statusShorter length of care

• Limit lipid to 12 % to 15 % of the NPC

• Medium-chain triglycerides are preferentially oxidized thus leaving little tendency for deposition of adipose tissue or clogging of the reticuloendothelial system of mitochondria

• Structure lipids may improve hepatic protein synthesis and reduce protein catabolism and energy expenditure

3. Protein

• Protein needs are elevated because of the ff:

Losses through urine and woundsIncreased use in gluconeogenesis and wound healing

• High-protein feeding is recommended

• Provision of 20% -25% of total calories

• Feeding 2.5 to 3.0 g/kg protein is suggested for thermally injured children

• Individual adult can be calculated by this formula:

1 g protein/ kg preborn weight + ( 3 g protein x % BSA burned)

• Most adults require an increasing amount of 1.3 to 3 g protein per kg of body weight to achieve nitrogen balance

• Ability to tolerate protein depends on renal function and fluid balance

• Arginine may improve cell-mediated immunity and wound healing, and also affects anabolic hormone production

• Glutamine enhances the ability of neutrophils to kill certain bacteria

• Monitor blood urea nitrogen, serum creatinine, and hydration when given high protein diet

4. Assessment of Energy and Protein Adequacy

• Best Evaluated by:Monitoring wound healing - delayed if weight loss

exceeds 10% of usual body weightMonitoring Graft take - delayed if weight loss

exceeds 10% of usual body weight Basic nutritional assessment parameters

• Exact evaluation of weight loss is hard to obtain due to fluid shift or edema or difference in weights of dressing or splints

• Evaluation of Nitrogen Balance through formulas for estimate wound nitrogen losses:

< 10% open wound= 0.02 g nitrogen/kg/day 11% to 30 % open wound= 0.05 g

nitrogen/kg/day >31% open wound= 0.12 g nitrogen/kg/day

• Nitrogen excretion decreases as wounds heal, grafted or covered

• Serum albumin levels, remain depressed until major burns are healed

• Serum prealbumin, retinol-binding protein, and transferrin are used to help assess protein status for burned patients

5. Vitamins and Minerals

RATIONALE FOR MICRONUTRIENT REQUIREMENT FOR BURNED PATIENTS

• Vitamin C- ( 500 mg twice a day)• Thiamin, riboflavin, Niacin • Vitamin A- 5000 IU per 1000 calories of enteral

nutrition)• Zinc- ( 220 mg zinc sulfate)

• Sodium- Hyponatrenia are seen in patients who have:

evaporative losses due to application of dressings or grafts

changes in maintenance fluidsbeen treated with silver nitrate soaks

• Potassium – Hypokalemia often occurs after the initial fluid resuscitation and during protein synthesis

• Calcium – Hypocalemia is seen in patients with more than 30% TBSA, especially when treated with silver nitrate soaks , this is accompanied by hypoalbuminemia.

• Phosphate – Hypophosphatemia occurs in patients who receive large volumes of resuscitation fluid along with parenteral infusion of glucose solution and large amounts of antacids for stress ulcer prophylaxis

• Magnesium- can be lost from burn wounds

• Iron- Anemia is seen following burn thus treated with packed red blood cells

6. Method of Nutrition Support

• Implemented in individual basis• Burns of less than 20% TBSA are able to meet

their needs with a regular, high-calorie and high protein diet

• Concealed nutrients such as adding protein to puddings, milk and gelatins

• Tube feeding is required for patients with:

Major burnsExtraordinarily high Energy

expenditurePoor appetites

• Enteral feeding is preferred method, but parenteral nutrition is necessary with early excision and grafting

• Ileus is often present so patients can be fed successfully into the small bowel

• IGF-1 and human growth hormone decreases the stress response and improve nitrogen balance in burn patients

• Anabolic steroids such as oxandrolone, when combined with a high-protein diet ( 2 g/kg/day) restores weight loss

• Total Parental Nutrition ( TPN) is a method of choice for patients with persistent ileus and high risk for aspiration or used for immediate replacement of fluids and electrolytes

Oral Solutions

• entered through the mouth • an example is Holdrane's Solution ( consists of 1/2 tsp or 4 g salt, 1 1/2 tsp or 2 g sodium bicarbonate or baking soda, and a liter of water)

* Burn patients are in pain, worried about disfigurement, and know they have long costly and painful stay in the hospital with the possibility of surgery, so they need a great deal of encouragement and understanding.

References

Claudio, V. et al. Medical Nutrition Therapy for Surgical Conditions. Medical Nutrition Therapy for Filipinos. Merriam & Webster bookstore, Inc. 2004. 3 ( 1-32).

Mahan, L. and Stump, S. Medical Nutrition Therapy for Metabolic

Stress: Sepsis,Trauma, Burns, and Surgery. Krause’s Food, Nutrition and Diet Therapy 11th Edition. USA: Elvesier. 2004. 1058-1078.

Clayman, C. The American Medical Association Encyclopedia of

Medicine. New York: Random House. 1989. http://www.burnsurgery.org/Modules/orders/sec2.htm