Group Presentation: Nutrition Support in the Burn Patient

Report
Nutrition Support in the
Burn Patient
Recommendations from a review of
literature
Kaitlin Deason
And
Confidential Group Members
S
Case study
S A 31 year old white male trapped in a burning apartment building decided
to jump from a window. Preassessment by emergency personnel revealed
burns to his extremities, scalp, face, thorax, and back (an estimated 90%
total body surface area burn). It also appeared he sustained a tibula/fibula
fracture of the left leg and a crush injury of the right ankle. He was brought
into the emergency room on a 100% oxygen non-rebreathing mask. In the
emergency room he was promptly intubated with an oral 7.5 ETT because
of suspected inhalation burns. Appropriate analgesics and IV fluids were
administered and the patient was placed on mechanical ventilation. He was
immediately taken to the burn unit and tanked. He then went to surgery to
repair and stabilize his fractures. The following day his total body surface
area burns were reassessed from 90% to 60%.
Outline of literature review
S What to monitor
S Why and what type of nutrition support to
provide
S Macronutrient considerations
S Micronutrient considerations
Why are burn patients so
difficult to manage?
S Severe metabolic stress
S Extreme shifts in fluids
S Can be difficult to stabilize depending on
degree of injury
Initial monitoring
Indications for EN and TPN
S A burn patient has high nutrient and calorie needs, and
these needs are often not met by the patients’ oral intake
S Enteral and total parenteral nutrition are two methods to
feed a patient who is either not eating orally or who is not
eating enough.
S It is usually protocol of the burn unit that enteral nutrition
be started within 12 hours of admission via nasogastric or
nasojejunal tube so long as the gut is still functioning
Indications for EN and TPN
Con’t.
S Enteral nutrition is the preferred nutrition method
S 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.”
Indications for EN and TPN
Con’t.
S Nutrition support has been shown to decrease the risk
of infections in the burn patient
S One review showed 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
Macronutrient
recommendations
S The initial goal is to provide adequate nutrition,
prevent lean muscle losses, and provide adequate
fluids.
S 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
Macronutrient
recommendations Con’t.
S The best estimate of energy needs would be to use
indirect calorimetry
S There is a difficult equation that can be used known
as the Ireton-Jones equation
S Takes into consideration trauma and burns
Macronutrient
recommendations Con’t.
S Caloric needs should be assessed to ensure the
patient is not losing weight more than 10% of their
usual body weight
S 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
S Fluids needs can also double but the varies in each
case based on the degree of the burn.
Macronutrient
recommendations Con’t.
S Two important essential amino acids to burn
recovery are glutamine and arginine
S 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
S Arginine stimulates growth hormone, which is required
for wound healing . However more research needs to be
conducted about the safety
Micronutrient recommendations
S Micronutrients are essential in endogenous
antioxidant defense mechanisms and immunity
S Critically ill burn patients are at high risk of
selenium, zinc, copper, vitamin C and vitamin E
deficiency
S One study indicated that high-dose ascorbic acid
infusion reduced resuscitation fluid requirements
through an endothelial antioxidant mechanism
Micronutrient recommendations
con’t
S Copper, selenium and zinc are key nutrients for
wound healing and immune defense
S Copper is essential for wound repair
S Zinc is essential for wound healing
S Selenium is essential for the activity of glutathione
peroxidase (GSHPx)
S Part of the body’s first line of antioxidant defense in
both intra-and extracellular compartments
Micronutrient recommendations
S A prospective, randomized, placebo-controlled trial
conducted by Berger et al. (2007) showed that large
and early intravenous combining of copper,
selenium, and zinc supplementation reduced
infection and improved wound healing after major
burns
S Therefore, supplementation of these particular
trace elements may be beneficial, but more
research is needed
Conclusions
S Burn patients can be particularly challenging to
manage but the research shows that 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.
S Clinicians should be particularly mindful of
macronutrients, micronutrients, monitoring, and
choosing the appropriate feeding method
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., Baines, M., Raffoul, W., Benathan, M., Chiolero, R.L., Reeves, C., Revelly, J., Cayeux, M., Senechaud, I., &
Shenkin, A. (2007). Trace element supplementation after major burns modulates antioxidant status and clinical course by way
of increased tissue trace element concentrations. American Journal of Clinical Nutrition, 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.

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