Nutrition Therapy in Nutrition Therapy in Burn-Injured PatientsBurn-Injured Patients

Robin Saucier, RD, CNSCRobin Saucier, RD, CNSC

28 September 201028 September 2010

Burn Incidence and Burn Incidence and TreatmentTreatmentIn U.S. annually:In U.S. annually:• 1,000,000 burns receiving medical 1,000,000 burns receiving medical

treatment treatment • 4,000 fire and burn deaths4,000 fire and burn deaths

– 75% occur at scene of incident or during 75% occur at scene of incident or during transporttransport

• 40,000 admissions to hospital 40,000 admissions to hospital – 25,000 to hospital with specialized burn center25,000 to hospital with specialized burn center

• 94.4% survival rate when admitted to a 94.4% survival rate when admitted to a specialized burn centerspecialized burn center– UCH is only ABA-verified burn center in ColoradoUCH is only ABA-verified burn center in Colorado

Source: American Burn Association National Burn Repository (2005 report)

Types of BurnsTypes of Burns

• Fire/flame (42%)Fire/flame (42%)• Scald (31%)Scald (31%)• Hot object contact (9%)Hot object contact (9%)• Electrical (4%)Electrical (4%)

– can continue to burn for up to weeks after can continue to burn for up to weeks after initial insult, organ failure without significant initial insult, organ failure without significant skin involvementskin involvement

• Chemical (3%)Chemical (3%)• Other – radiation, skin disease, or Other – radiation, skin disease, or

unspecified/unknown etiology (6%)unspecified/unknown etiology (6%)

Source: American Burn Association National Burn Repository (2010 report)

Other conditions & Other conditions & considerationsconsiderations

• Stevens-Johnson syndromeStevens-Johnson syndrome

• Necrotizing fasciitisNecrotizing fasciitis

• Inhalation injuryInhalation injury

Pathophysiology of BurnsPathophysiology of Burns

SeveritySeverity– %TBSA%TBSA– Depth of skin injury Depth of skin injury

• Superficial (1Superficial (1stst degree)degree)

• Partial thickness (2Partial thickness (2ndnd degree) degree)

• Full-thickness (3Full-thickness (3rdrd/4/4thth degree) – incl muscledegree) – incl muscle

• ≥≥33rdrd degree requires degree requires graftinggrafting

Biphasic Metabolic Biphasic Metabolic ResponseResponse• Ebb PhaseEbb Phase Decrease in: cardiac output, oxygen Decrease in: cardiac output, oxygen

consumption, REE, body temp, tissue perfusion.consumption, REE, body temp, tissue perfusion.• Flow PhaseFlow Phase

– Acute responseAcute response: Increase in: acute-phase proteins, : Increase in: acute-phase proteins, catecholamines, cortisol, glucagon, cytokines, O2 catecholamines, cortisol, glucagon, cytokines, O2 consumption, REE, temp, tissue perfusion.consumption, REE, temp, tissue perfusion.

– Adaptive responseAdaptive response: Decrease in hypermetabolic rate, : Decrease in hypermetabolic rate, potential for restoration of body protein/LBM – can last for potential for restoration of body protein/LBM – can last for 9-12 months post-burn.9-12 months post-burn.

• Fluid resuscitation:Fluid resuscitation: LR (per Parkland formula: LR (per Parkland formula: 4ml/kg/%TBSA over first 24h) – can gain 5-13L of 4ml/kg/%TBSA over first 24h) – can gain 5-13L of fluidfluid

• Metabolic rate peaks around 7-10 days post-burn.Metabolic rate peaks around 7-10 days post-burn.

Importance of Nutrition Importance of Nutrition Intervention in BurnsIntervention in Burns

Protein-energy malnutrition occurs Protein-energy malnutrition occurs rapidly in burns and causes:rapidly in burns and causes:

• Impaired wound healingImpaired wound healing

• Muscle wastingMuscle wasting

• Immunocompetence for months after Immunocompetence for months after initial injuryinitial injury

• Growth retardation in childrenGrowth retardation in children

Factors in AssessmentFactors in Assessment• Severity (%TBSA/depth)Severity (%TBSA/depth)

• AgeAge

• SexSex

• Ventilatory statusVentilatory status

• Inhalation injuryInhalation injury

• Concomitant injuries Concomitant injuries

• Medications/IV dripsMedications/IV drips

• Co-morbidities/PMHCo-morbidities/PMH

• Pre-burn nutritional statusPre-burn nutritional status

Nutrition Assessment: Nutrition Assessment: CaloriesCalories• Use pre-burn or usual weight, if Use pre-burn or usual weight, if

known (fluid resuscitation may alter known (fluid resuscitation may alter admit weight; ICU body wts not admit weight; ICU body wts not accurate indicator of body cell mass). accurate indicator of body cell mass).

• Adjusted body weight is appropriate Adjusted body weight is appropriate with obesity (>120% IBW)with obesity (>120% IBW)

• Use actual body weight even if below Use actual body weight even if below 100% ideal100% ideal

Calculating Energy Calculating Energy RequirementsRequirements• Harris-Benedict equation x 1.5-2.0Harris-Benedict equation x 1.5-2.0• Ireton-Jones equation: Ireton-Jones equation:

EEE(v) = 1784 - 11(A) + 5(W) + 244 (S) + 239 (T) + EEE(v) = 1784 - 11(A) + 5(W) + 244 (S) + 239 (T) + 804 (B)804 (B)

EEE(s) = 629 - 11 (A) + 25 (W) - 609 (O)EEE(s) = 629 - 11 (A) + 25 (W) - 609 (O)

EEE=kcal/day: s=spontaneously breathing, EEE=kcal/day: s=spontaneously breathing, v=ventilator-dependent; A=age (yrs); W=body v=ventilator-dependent; A=age (yrs); W=body weight - (actual dry weight) (kg); S=sex (male=1, weight - (actual dry weight) (kg); S=sex (male=1, female=0); T = trauma, B= burn, O=obesity female=0); T = trauma, B= burn, O=obesity defined as BMI>27 (if present=1, absent=0).defined as BMI>27 (if present=1, absent=0).

Calculating Energy Calculating Energy RequirementsRequirements• 25-45 kcal/kg25-45 kcal/kg

• Curreri equation (be careful, often Curreri equation (be careful, often overestimates):overestimates):16-59yo: (25 x weight) + (40 x %TBSA) 16-59yo: (25 x weight) + (40 x %TBSA)

• Carlson equationCarlson equationREE for non-vented pt = BMR (0.89142 + REE for non-vented pt = BMR (0.89142 +

0.01335 × TBSA) × m0.01335 × TBSA) × m²² × 24 × activity × 24 × activity factor of 1.25factor of 1.25

Calculating Energy Calculating Energy Requirements: CaveatsRequirements: Caveats• Energy surge reaches its peak around 7-10 Energy surge reaches its peak around 7-10

days post-burndays post-burn• Milner et al found that predictive equations Milner et al found that predictive equations

most accurate in first 30 days post-burnmost accurate in first 30 days post-burn• Predictive equations may over-estimate Predictive equations may over-estimate

with sedation, paralytics (paralytics may with sedation, paralytics (paralytics may decrease EE as much as 30%).decrease EE as much as 30%).

• Indirect calorimetry most accurate but Indirect calorimetry most accurate but limitations. Utility of NICO? limitations. Utility of NICO? – NICO KCAL UTILIZATION: NICO KCAL UTILIZATION:

• VCO2 X 5.54 X 1440 = KCAL/Day

Nutrition Assessment: Nutrition Assessment: ProteinProtein

• Primary goal is healing, closure, LBM Primary goal is healing, closure, LBM sparing: do not reduce protein to preserve sparing: do not reduce protein to preserve renal function.renal function.

• Significant protein loss via wound exudate Significant protein loss via wound exudate despite nutrition supportdespite nutrition support– Estimated 110g/d during first 10 days post-burnEstimated 110g/d during first 10 days post-burn

• Estimated protein needs (depending on Estimated protein needs (depending on TBSA):TBSA):– 20-25% overall calories20-25% overall calories– Superficial: 1.5-2.0 g/kg/dSuperficial: 1.5-2.0 g/kg/d– Partial thickness: 2.0-2.5g/kg/dPartial thickness: 2.0-2.5g/kg/d– Full thickness 2.5-3.0g/kg/dFull thickness 2.5-3.0g/kg/d– In some cases up to 4g/kg/d/dIn some cases up to 4g/kg/d/d

Nitrogen BalanceNitrogen Balance

• Nitrogen balance = Nitrogen balance = N2N2 intake – (total intake – (total UUN + fecal N2 loss + wound loss)UUN + fecal N2 loss + wound loss)– ≤≤10% TBSA open wound: 0.02g 10% TBSA open wound: 0.02g

N2/kg/dayN2/kg/day– 11-30% TBSA open wound: 0.05g 11-30% TBSA open wound: 0.05g

N2/kg/dayN2/kg/day– ≥≥30% TBSA open wound: 0.12g 30% TBSA open wound: 0.12g

N2/kg/dayN2/kg/day

Nutrition Assessment: Nutrition Assessment: GlutamineGlutamine

• Only if NOT enrolled in Re-ENERGIZE. Only if NOT enrolled in Re-ENERGIZE. – Defer to unit RD if unsure or patient may Defer to unit RD if unsure or patient may

still be enrolled.still be enrolled.

• Recommended dosage: Recommended dosage: – 0.5g glutamine/kg/day0.5g glutamine/kg/day

• Dosage is in 10g increments, given Dosage is in 10g increments, given as bolus via FT in wateras bolus via FT in water

Glutamine Glutamine StudyStudy

• Based on the following hypotheses:Based on the following hypotheses:– Enteral glutamine administration in adult Enteral glutamine administration in adult

subjects with severe thermal burn injuries subjects with severe thermal burn injuries decreases:decreases:• In-hospital mortalityIn-hospital mortality

• Morbidity and length of careMorbidity and length of care

• The cost of careThe cost of care

• Inclusion CriteriaInclusion Criteria– ≥≥20% TBSA20% TBSA– Deep 2Deep 2ndnd and/or 3 and/or 3rdrd degree burns requiring degree burns requiring

graftinggrafting– Age + TBSA = 60-119Age + TBSA = 60-119

• Exclusion CriteriaExclusion Criteria– ≥≥48 hours from admission to ICU to time of consent (if 48 hours from admission to ICU to time of consent (if

transferred may be enrolled up to 96 hrs post-burn at site transferred may be enrolled up to 96 hrs post-burn at site investigator’s discretion)investigator’s discretion)

– Patients >80 yrs or <18 yrs of agePatients >80 yrs or <18 yrs of age– Liver cirrhosis – Child’s class C liver diseaseLiver cirrhosis – Child’s class C liver disease– PregnancyPregnancy– Associated multiple fractures or severe head traumaAssociated multiple fractures or severe head trauma– Absolute contraindication for EN (intestinal occlusion or Absolute contraindication for EN (intestinal occlusion or

perforation, abdominal injury)perforation, abdominal injury)– Patients with injuries from high voltage electrical shockPatients with injuries from high voltage electrical shock– Patients who are moribundPatients who are moribund– Patients with BMI <18 or >50Patients with BMI <18 or >50– Enrollment in another industry-sponsored ICU intervention Enrollment in another industry-sponsored ICU intervention

studystudy

Glutamine Glutamine StudyStudy

• Prescribed energy needs:Prescribed energy needs:– Indirect calorimetry Indirect calorimetry

• Measured energy expenditure x 1.0-1.3, ORMeasured energy expenditure x 1.0-1.3, OR

– Ireton-Jones equation, ORIreton-Jones equation, OR– Basal energy expenditure using Harris-Basal energy expenditure using Harris-

Benedict equationBenedict equation– If If ≥50% TBSA, use BEE x 1.7-2.0≥50% TBSA, use BEE x 1.7-2.0– If ≤50% TBSA, use BEE x 1.5-1.6If ≤50% TBSA, use BEE x 1.5-1.6

• Energy needs to be adjusted according to Energy needs to be adjusted according to progression of wound healing.progression of wound healing.

Glutamine StudyGlutamine Study

Glutamine Glutamine StudyStudy

• Prescribed Protein NeedsPrescribed Protein Needs– If If ≥50% TBSA, use 2.0-3.0g/kg/d≥50% TBSA, use 2.0-3.0g/kg/d– If ≤50% TBSA, use 1.5-2.0(+) g/kg/dIf ≤50% TBSA, use 1.5-2.0(+) g/kg/d

• Protein needs to be adjusted Protein needs to be adjusted according to progression of wound according to progression of wound healing & other biochemical markers.healing & other biochemical markers.

• Glutamine not included in protein Glutamine not included in protein allocation.allocation.

Feeding ModalitiesFeeding Modalities

• If If <20% TBSA, can trial high kcal/prot diet <20% TBSA, can trial high kcal/prot diet with po supps, calorie count. 10-20% with po supps, calorie count. 10-20% TBSA may still need enteral nutrition if po TBSA may still need enteral nutrition if po suboptimal.suboptimal.

• If ≥20% TBSA or <90% IBW, EN indicated. If ≥20% TBSA or <90% IBW, EN indicated. Usually started within first 24h of Usually started within first 24h of admission.admission.

• TPN only indicated when EN fails, or in TPN only indicated when EN fails, or in cases of abdominal compartment cases of abdominal compartment syndrome, significant pressor usage, etc.syndrome, significant pressor usage, etc.

Enteral NutritionEnteral Nutrition• Feeding tubes placed within 4 hours of admission, Feeding tubes placed within 4 hours of admission,

EN started as soon as placement confirmedEN started as soon as placement confirmed• Osmolite 1.2/1.5 as standard formulaOsmolite 1.2/1.5 as standard formula• If +inhalation injury, SIRS/sepsis, ALI, ARDS: If +inhalation injury, SIRS/sepsis, ALI, ARDS:

consider Oxepa (caution with large burns – high consider Oxepa (caution with large burns – high fat, vitamin A content)fat, vitamin A content)

• If co-morbid conditions indicate (e.g., neuro If co-morbid conditions indicate (e.g., neuro trauma), can use Nutren 2.0 for lower carb, fluid trauma), can use Nutren 2.0 for lower carb, fluid content.content.

• Pt may become hypernatremic, TF’s may be Pt may become hypernatremic, TF’s may be changed to diluted (1:1, 1:2 with H2O)changed to diluted (1:1, 1:2 with H2O)

• Prune juice often added as part of bowel regimen, Prune juice often added as part of bowel regimen, especially with rectal tube.especially with rectal tube.

• Include kcal given from Prostat in total kcals Include kcal given from Prostat in total kcals estimated/receivedestimated/received

Additional SupplementationAdditional Supplementation• Daily MVIDaily MVI• 500mg Ascorbic Acid BID500mg Ascorbic Acid BID• 220mg Zinc (if not receiving IV trace 220mg Zinc (if not receiving IV trace

elements) – length of tx unknown (10-elements) – length of tx unknown (10-14 days?)14 days?)

• ? 10,000 IU Vitamin A? 10,000 IU Vitamin A• Oxandrolone (anabolic steroid to Oxandrolone (anabolic steroid to

decrease loss of LBM, promote wound decrease loss of LBM, promote wound healing, counteract lysis during healing, counteract lysis during hypermetabolic state)hypermetabolic state)

• IV Trace elements (copper, zinc, IV Trace elements (copper, zinc, selenium) for >20% TBSA. Requires selenium) for >20% TBSA. Requires central access.central access.– 14d course for 20-60% burn14d course for 20-60% burn– 21d course for >60% burn21d course for >60% burn

Monitoring: Clinical CourseMonitoring: Clinical Course

• Review: Residuals, abd exam, stool output Review: Residuals, abd exam, stool output (rectal tube), I/O’s, significant changes in (rectal tube), I/O’s, significant changes in insulin gtt ratesinsulin gtt rates

• Surgical course: OR/grafting, wound healing Surgical course: OR/grafting, wound healing (% open wound) – closure may not (% open wound) – closure may not significantly decrease hypermetabolic significantly decrease hypermetabolic response.response.

• Indirect calorimetry as indicated (appropriate Indirect calorimetry as indicated (appropriate with large burns when pt not responding to with large burns when pt not responding to current nutrition therapy)current nutrition therapy)

Monitoring: Lab ValuesMonitoring: Lab Values

• Prealbumin & CRP Prealbumin & CRP checked Q Monday checked Q Monday

• Sodium – loop diuretics, Sodium – loop diuretics, wound losses, fluid wound losses, fluid overload, hypertensionoverload, hypertension

• Potassium – wound Potassium – wound losses, diuretic therapy, losses, diuretic therapy, renal failurerenal failure

• Calcium – wound losses, Calcium – wound losses, chronic immobilitychronic immobility

• Phosphorus – immobility, Phosphorus – immobility, renal failurerenal failure

Adjusting NeedsAdjusting Needs

• Needs max around 7-10 days post-burnNeeds max around 7-10 days post-burn• May consider adjusting needs weekly until May consider adjusting needs weekly until

burns coveredburns covered• Predictive equations may not be reliable Predictive equations may not be reliable

after 30 days post-burnafter 30 days post-burn• Adjust needs for % open area:Adjust needs for % open area:

– Decreases needs: grafting, re-epithelializationDecreases needs: grafting, re-epithelialization– Increases needs: wound infection, graft loss, Increases needs: wound infection, graft loss,

donor sitesdonor sites

Long-term Follow-upLong-term Follow-up

• Cycling TF’s: Allow for improved Cycling TF’s: Allow for improved appetite as po increases appetite as po increases – 50-100% TF volume often delivered over 50-100% TF volume often delivered over

12-16h if pt can tolerate volume until po 12-16h if pt can tolerate volume until po >50% est needs.>50% est needs.

• Calorie countCalorie count

• High calorie/high protein dietHigh calorie/high protein diet

• Oral supplementationOral supplementation

Why we do itWhy we do it

ReferencesReferences

• Gottschlich MM, Mayes T. Burns. In: Merritt R ed. Gottschlich MM, Mayes T. Burns. In: Merritt R ed. The Aspen Nutr The Aspen Nutr Support Practice Manual. Support Practice Manual. 22ndnd ed ed. . 2005:296-300. Silver Spring, MD: 2005:296-300. Silver Spring, MD: ASPEN.ASPEN.

• Chan MM, Chan MM. Nutritional therapy for burns in children and Chan MM, Chan MM. Nutritional therapy for burns in children and adults. Nutrition, March 2009 25(3): 261-9. adults. Nutrition, March 2009 25(3): 261-9.

• Carlson DE et al. Resting energy expenditure in patients with Carlson DE et al. Resting energy expenditure in patients with thermal injuries. thermal injuries. Surg Gynecol Obstet. Surg Gynecol Obstet. 174(4):270-6.174(4):270-6.

• Milner EA et al. A longitudinal study of resting energy expenditure in Milner EA et al. A longitudinal study of resting energy expenditure in thermally injured patients. thermally injured patients. J Trauma.J Trauma. 37(2):167-70. 37(2):167-70.

• Cresci G, Gottschlich MM, Mayes T, Mueller C. Trauma, Surgery, and Cresci G, Gottschlich MM, Mayes T, Mueller C. Trauma, Surgery, and Burns. In: Gottschlich MM ed. Nutr Support Core Curriculum: A Case-Burns. In: Gottschlich MM ed. Nutr Support Core Curriculum: A Case-Based Approach – the Adult Patient. 2007:455-476. Silver Spring, Based Approach – the Adult Patient. 2007:455-476. Silver Spring, MD: ASPEN.MD: ASPEN.

• Berger MM. Antioxidant micronutrients in major trauma and burns: Berger MM. Antioxidant micronutrients in major trauma and burns: evidence and practice. evidence and practice. Nutr Clin Practice. Nutr Clin Practice. 2006;21(5):438-446.2006;21(5):438-446.

• Berger MM et al. Reduction of nosocomial pneumonia after major Berger MM et al. Reduction of nosocomial pneumonia after major burns by trace element supplementation: aggregation of two burns by trace element supplementation: aggregation of two randomised trials. randomised trials. Crit CareCrit Care. 2006; 10:R153.. 2006; 10:R153.