fcs 690a lit review paper -...
TRANSCRIPT
NNNuuutttrrriiitttiiiooonnn SSSuuuppppppooorrrttt iiinnn ttthhheee BBBuuurrrnnn PPPaaatttiiieeennnttt
RRReeecccooommmmmmeeennndddaaatttiiiooonnnsss fffrrrooommm aaa rrreeevvviiieeewww ooofff llliiittteeerrraaatttuuurrreee
FFFCCCSSS 666999000AAA KKKaaaiiitttllliiinnn DDDeeeaaasssooonnn
AAAnnnddd CCCooonnnfffiiidddeeennntttiiiaaalll GGGrrrooouuuppp MMMeeemmmbbbeeerrrsss
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.