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NUTRITION SUPPORT IN THE BURN PATIENT 2

Introduction

For this literature review we evaluated the nutrition recommendations for patients with

severe burns. Since burn patients experience such extreme metabolic stress and fluid shifts, they

can be tremendously difficult to manage on the nutrition front. Evidence has shown that without

adequate nutrition support there can be severe deficits leading to adverse outcomes in burn

patients. The literature reviewed provides the most important guidelines for caring for a critical

burn patient.

Initial Monitoring of the Burn Patient

The condition of a burn patient can change very rapidly due to the high metabolic stress

in a burn patient. Therefore, there are many important labs to monitor in these patients (Demling,

DeSanti, & Orgill, 2004). The following table summarizes some of the most important labs to

monitor:

In burn patients, the largest initial concern is hypervolemia due to severe shifts in fluids and

protein. As a result, the most important thing to obtain from the labs is how much fluids are

needed to stabilize the patient. Once the patient is stabilized, additional monitoring is required.

Enteral and Parenteral Indications in Burn Patients

Nutrition assessment is key in determining a patient’s nutritional needs. When a burn

Lab Purpose Body weight To determine nutrient and fluid needs. Pulse Helps determine fluid needs. Pulse >130 needs more fluids. Intake-Output Helps determine fluid needs. Blood gasses Indicates tissue oxegenation. ECG Arrythremia is a common burn response in those >45 years. Body temperature Watch for hypothermia. Hemoglobin and Hematocrit Measurement of blood volume. Electrolytes (Na, Cl, K) To prevent excess losses. PT, PTT, and Platelets To determine if clotting factors are needed

NUTRITION SUPPORT IN THE BURN PATIENT 3

patient is first admitted to a hospital their pre-burn history is noted, as well as height, weight,

injury, and nutritional status (Prelack, Dylewski, & Sheridan 2007). The nutritional status of a

patient is critical to the process of determining Total parental nutrition (TPN) needs in order to

avoid the possibility of refeeding syndrome. Weight cannot be the only factor when assessing the

burn patient because it can be obscured based on the expansion of extracellular water caused by

the burn injury. The best indicator of nutritional status in a burn patient’s is the visceral protein

because this value determines the phase of injury, directly indicative of the patient’s

physiological stress.

A burn patient has high nutrient and calorie needs, and these needs are often not met by

the patients’ oral intake. Enteral and total parenteral nutrition are two methods to feed a patient

who is either not eating orally or who is not eating enough. TPN therapy, as Mahn & Escott-

Stump indicate, can be used when the patient frequents surgery enough that the feeding may be

interrupted by the anesthesia (2008). This method would ensure the patient was continuously

consuming the desired nutrients. Enteral nutrition (EN) however is the preferred nutrition

method because it can provide a large amount of nutrients and fluids and it uses the

gastrointestinal system versus the body’s veins, thus utilizing the body’s natural method of

absorption. An article by Chan & Chan (2009) states that “early enteral feeding within 24 hours

of hospitalization has been shown to decrease the hypercatabolic response, thus decreasing the

release of catecholamine glucagon, and weight loss, improve caloric intake, stimulate insulin

secretion, improve protein retention, and shorten hospital length of stay.” Enteral feeding acts as

a conduit for the delivery of immune stimulants and nutrients that the patient will need to heal

properly. Usually, it is protocol of the burn unit that enteral nutrition to be started within 12

hours of admission via nasogastric or nasojejunal tube so long as the gut is still functioning

NUTRITION SUPPORT IN THE BURN PATIENT 4

(Berger et al., 2007).

The use of nutrition support has been shown to decrease the risk of infections in the burn

patient (Gaby, 2010). Alan Gaby stated in his review that the use of intravenous infusions with

trace minerals zinc, copper and selenium administered with a 0.9% saline solution started within

twelve hours after the injury and continued for fourteen days after the burn had a 42% lower

chance of receiving an infection than the control group who received normal saline (2010). Gaby

also noted that the results were due to an improvement in wound healing compared to the control

group. As shown by this review, nutrition support enables a great chance of a healthy recovery

post treatment for the burn patient.

Macronutrient and Micronutrient Concerns in Burn Patients

The initial goal is to provide adequate nutrition and prevent lean muscle losses, but based

on the increased needs of burn patients there are also clear macro and micronutrient changes that

need to be considered. In a burn patient, metabolic stress is going to limit the ability of providing

optimal nutrition. Each person burn patients can be very different from the last. Therefore, every

burn patient needs to be treated as an individual based on the degree of the burn and the amount

of stress caused to the body. When estimating a patient’s energy expenditure it is important to be

mindful of the various conditions affecting the patient. For example, there should be

environmental measures to minimize heat loss, pain management, sedation, and ventilator

support and nutrition therapy (Prelack, Dylewski, & Sheridan 2006). The goal in nutrition

therapy is to protect the lean tissue mass and function within the patient, since the highest losses

seem to occur in severe burn patients (Hoffer, 2003). The best estimate of energy needs would be

to conduct an indirect calorimetry (Prelack, Dylewski, & Sheridan 2007).

After a severe burn the body requires help to recuperate and begin the healing process.

NUTRITION SUPPORT IN THE BURN PATIENT 5

Caloric needs should be assessed to ensure the patient is not losing weight more than 10% of

their usual body weight. Many patients can become anorexic during the healing process, so

medical nutrition therapy indicates that the caloric needs can be increased by 20%-30% the

normal range to account for wound care and physical therapy needs the patient will have (Mahn

& Escott-Stump, 2008). A formula has been developed to calculate the needs of the patients. The

Ireton-Jones equation is as follows: Estimated Energy Expenditure= 1784-11(Age) + 5(Weight

kg) + 244(Gender [male=1, female=0]) + 239(Diagnosis of trauma [absent= 0, present=1]) + 804

(Diagnosis of burn [absent=0, present=1]) (Mahn & Escott-Stump, 2008). This is a standard,

well used, formula to calculate calories but it should be noted that calories can be increased up

to100% of the resting energy expenditure to provide individualistic care to the patient.

In TPN, the basis for burn patients is a maximum glucose infusion rate is 5mg/kg/minute

because glucose cannot oxidize efficiently in adults or children. Past studies have shown the

beneficial amount of protein is 1.5g/kg/day, because this amount creates the prefect protein

synthesis and protein breakdown balance with a burn patient. Intravenous lipids are avoided

unless patients needs parenteral nutrition for longer then 3 weeks. The reasoning is lipids are

more likely to be involved in fatty-acid triglyceride recycling during inflammation and less likely

to help with protein sparing than glucose. In a burn patient it is of most importance to provide

enough protein, proper supplementation of protein within the healing time will result in good

surgical outcomes and less weight loss (Prelack, Dylewski, & Sheridan 2006).

In EN, when picking a formula the two important essential amino acids are glutamine and

arginine. Glutamine serves as a primary oxidative fuel source for rapid dividing cells because of

this it has been shown to be moderately beneficial in burn patients. Glutamine also decreases

protein muscle breakdown and increases wound healing. The other important amino acid is

NUTRITION SUPPORT IN THE BURN PATIENT 6

arginine, which is considered to be semi-essential in burn patients. This is because it stimulates

growth hormone, which is required for wound healing. Although arginine has been shown to be

useful in wound healing more research needs to be conducted about the safety (Prelack,

Dylewski, & Sheridan 2007).

Micronutrient’s role has been growing and essential in endogenous antioxidant defense

mechanisms and immunity. Critically ill burn patients are at high risk of selenium, zinc, copper,

and vitamin C and E deficiency. Human trials and studies showed that early intervention of

micronutrients in the course of major burns is safe and effective in recovery. Continuous high-

dose ascorbic acid infusion achieves reduction of resuscitation fluid requirements by endothelial

antioxidant mechanisms both in animal models and in 1 human trial (Berger, 2006).

Major burn causes nutritional deficiencies including trace elements in particular copper,

selenium and zinc severely depleted as the result of extensive losses; key nutrients for wound

healing and immune defenses. Copper is essential for wound repair, zinc for wound healing and

selenium is essential for the activity of glutathione peroxidase (GSHPx), belong to the body’s

first line of antioxidant defense in both intra-and extracellular compartments (CITE!!).

A prospective, randomized, placebo- controlled trial results has been shown that a large

and early intravenous combining copper, selenium, and zinc supplementation reduced infection

and improved wound healing after major burns. However, more research is needed to confirm

these outcomes (Berger, & et al, 2007).

Several studies were comparing early verses delayed enteral nutrition (EN) in critically

burn patients and preferred enteral nutrition over parenteral. Chiarelli and colleagues examined

20 patients with 25% to 60% body surface area (BSA) burns and noted that early EN is

beneficial and effective as results were indicated positive nitrogen balance in burn patient

NUTRITION SUPPORT IN THE BURN PATIENT 7

(Curtis, & Kudsk, 2009).

Conclusion

It is clear from the literature that burn patients can particularly challenging to manage.

However, if clinicians bear in mind the guidelines presented in this review it is possible to

achieve positive outcomes. There are many considerations when treating a burn patient including

macronutrients, micronutrients, monitoring, and choosing the appropriate feeding method. By

providing adequate protein and fluids along with the recommended micronutrients and trace

elements the recovery of a burn patient can be greatly enhanced through nutrition support.

NUTRITION SUPPORT IN THE BURN PATIENT 8

References

Berger, M.M. (2006). Antioxidant micronutrient in major trauma and burns: evidence and

practice. Nutrition in Clinical Practice, 21(5). Retrieved from

http://ncp.sagepub.com/content/21/5/438.abstract doi: 10.1177/0115426506021005438

Berger, M.M., et.al (2007). Trace element supplementation after major burns modulates

antioxidant status and clinical course by way of increased tissue trace element

concentrations. Amer i can Journa l o f C l i n i ca l Nu t r i t i on , 85 ( 5 ) , 1293 -

1300 .

Chan, M.M., & Chan, G.M., (2009). Nutritional therapy for burns in children and adults.

Nutrition (25)3, 261-269.

Curtis, C.S., & Kudsk, K.A. (2009). Enteral feeding in hospitalized patients: early versus

delayed enteral nutrition. School of Medicine, University of Virginia, USA. Retrieved

from http://www.medicine.virginia.edu/clinical/departments/medicine/

divisions/digestive-health/nutrition-support-team/nutritionarticles/CurtisArticle. Pdf

Demling, R. H., DeSanti, L, & Orgill, D. P. (2004). Educating the burn care professionals around

the world. Burnsurgery.org. Retrieved from http://www.burnsurgery.org/

Gaby, A. (2010). Nutrition treatment for burns. Integrative Medicine (9)3, 46-51.

Hoffer, J. (2003) Protein and energy provision in critical illness. The American Journal of

Clinical Nutrition, 78, 906-911.

Mahan, L. K., & Escott-Stump, S. (2008). Krause's food, nutrition, & diet therapy. Philadelphia:

W.B. Saunders.

Prelack, K., Dylewski, M., & Sheridan, R. L. (2007) Practical guidelines for nutritional

management of burn injury and recovery. Burns, 33, 14-24.