Nutritional Needs of the Burn Patient Joan LeBoeuf, RD, CNSD UNM Burn Center Adult & Pediatric Injury from tragedy… hope! Topics of Discussion • • • • • Kcal Needs Protein Needs Micronutrient Supplementation Methods of Nutrient Delivery Nutritional Monitoring UNM Burn Center: from tragedy… hope! Nutrition … A Crucial Component of Care • Hypermetabolism – Burns=Highest kcal needs than that of any other injury or disease – Proportional to the extent of the burn injury • Hypercatabolism – Burns=Highest protein needs – Erosion of lean body mass • Adequate nutrition = Successful wound healing Role of Specific Nutrients: Kilocalories • Kcals – Supplied by carbohydrate, protein, fat – Needed for optimal tissue repair – Required for synthesis of new cells – Sufficient calories is a priority so that protein will be spared Determining Kcal Needs • Calculation of energy needs for the burn patient remains challenging – % TBSA – Degree of burn – Other trauma involved Determining Kcal Needs • Predictive formulas – At least 30 formulas have been proposed • Harris-Benedict Equation: adds activity factor and stress factor • Ireton-Jones Equation: accounts for age, weight, gender, presence of trauma or burn, and ventilatory status • Kcalories/kg – Used for less severe burns (<20% TBSA) Determining Kcal Needs • Indirect Calorimetry (Metabolic Cart) – Considered to be the “gold standard” – An indirect method of calculating energy expenditure and respiratory quotient using measurements of inspired and expired gas – Most closely related to actual energy expenditure – Accounts for variability in energy expenditure from changes in metabolic state Determining Kcal Needs – Indirect Calorimetry, continued • Requirements for a valid measurement: – Hemodynamically stable patient – A cooperative or sedated patient – Period of rest before measurement – FiO2 < 60% – Absence of chest tubes or other sources of air leak Role of Specific Nutrients: Protein – Needed for cell multiplication, collagen and connective tissue formation and increased enzyme activity – The nutrient most compromised by burn injury – Extensive nitrogen losses, relative to wound size, are noted in wound exudate and urine – Protein needs • 20-25% of kcals • 1.5 to 3.0 g/kg Role of Specific Nutrients: Micronutrients • Severely burned patients (>20% TBSA) may require micronutrient supplementation due to metabolic changes and increased losses from wounds. – vitamin A, vitamin C, Zinc, multivitamin • <20% TBSA, a multivitamin alone may be sufficient to meet needs Micronutrient Guidelines After Thermal Injury • Adults and Children (>3y, >40 lbs, >20% TBSA) – – – – 1 multivitamin q day 500 mg ascorbic acid bid 10,000 IU vitamin A q day** 220 mg zinc sulfate q day • **For tube-fed patients, vitamin A supplementation should be discontinued once the feeding formula is administered at a rate that would meet vitamin A requirements. Micronutrient Guidelines After Thermal Injury • Children (<3y, <40 lbs, >10% TBSA) – – – – 1 children’s multivitamin q day 250 mg ascorbic acid bid 5000 IU vitamin A q day** 110 mg zinc sulfate q day • **For tube-fed patients, vitamin A supplementation should be discontinued once the feeding formula is administered at a rate that would meet vitamin A requirements. Methods of Nutrient Delivery • Oral Intake – Burns <25% TBSA in older children and adults and <15% TBSA in young children and infants – High-calorie, high-protein supplements – Modular calorie and protein enhancement of oral foodstuffs Methods of Nutrient Delivery • Enteral Nutrition (EN) – Most burn patients can tolerate a standard formula – Formula with high nitrogen content – Transpyloric feedings are better tolerated – EN is preferred to parenteral nutrition (PN) Methods of Nutrient Delivery • Parenteral Nutrition (PN, TPN, PPN) – Associated with complications • • • • Intestinal dysmotility Hepatic steatosis Septic morbidity Catheter-related infection – ASPEN guidelines: limit use of PN to patients in whom EN is contraindicated or unlikely to meet nutritional needs in 4-5 days Monitoring Nutritional Status • Body Weight – Weight should be measured regularly – Goal of weight maintenance is within 90%-110% of preburn weight • Prealbumin – Short half-life of 2-3 days – Reflects recent nutrition intake – Depressed during acute phase response to burn Monitoring Nutritional Status • Nitrogen Balance – Evaluates the adequacy of protein intake – Needs a 24 hour urine collection and a 24 hr UUN lab test – Nitrogen balance = nitrogen intake - nitrogen losses Monitoring Nutritional Status • Nitrogen Balance, continued – Nitrogen intake = protein intake/6.25 – Nitrogen losses = • Urinary nitrogen losses (24 hr UUN) • Other losses from non-urea urinary nitrogen, fecal, sweat, etc. (3-5 g) • Burn wound nitrogen losses – <10% open wound = 0.02 g/kg – 11% to 30% open wound = 0.05 g/kg – >30% open wound = 0.12 g/kg Monitoring Nutritional Status • Indirect Calorimetry (Metabolic Cart) – Periodic measurements aid in evaluating adequacy of caloric intake – Measures resting energy expenditure (REE) • A factor of 10% to 30% added for calorie needs during PT and wound care Conclusions • An aggressive nutrition approach for the burn patient is indicated to: – address hypermetabolism – enhance nitrogen retention – support wound healing – improve survival References • ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr. 2002;26(suppl):S88-S90. • Mayes T, Gottschlich MM. Burns and wound healing. In: Gottschlich M, Fuhrman MP, Hammond KA, Holcombe BJ, Seidner, DL, eds. The Science and Practice of Nutrition Support: A Case-based Core Curriculum. Dubuque, Ia: Kendall/Hunt Publishing Co; 2001:391-420. • Lefton J. Specialized Nutrition Support for Adult Burn Patients. Support Line. 2003;25(4);19-25. • Trujillo E, Robinson M, Jacobs J. Critical Illness. In: The ASPEN Nutrition Support Practice Manual. Silver Spring, MD: ASPEN; 1998:18-1-18-14. Questions… one child burned, is one child too many! Joan LeBoeuf, RD, CNSD UNM Burn Center Adults & Pediatrics from tragedy… hope!