Kaitlin Deason And Confidential Group Members Nutrition Support in the Burn Patient Recommendations from a review of literature Kaitlin Deason And Confidential Group Members

Case study 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 What to monitor Why and what type of nutrition support to provide Macronutrient considerations Micronutrient considerations

Why are burn patients so difficult to manage? Severe metabolic stress Extreme shifts in fluids Can be difficult to stabilize depending on degree of injury

Initial monitoring

Indications for EN and TPN 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. 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. Enteral nutrition is the preferred nutrition method 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.” 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.

Indications for EN and TPN Con’t. Nutrition support has been shown to decrease the risk of infections in the burn patient 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 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.

Macronutrient recommendations The initial goal is to provide adequate nutrition, prevent lean muscle losses, and provide adequate fluids. 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. The best estimate of energy needs would be to use indirect calorimetry There is a difficult equation that can be used known as the Ireton-Jones equation Takes into consideration trauma and burns

Macronutrient recommendations Con’t. Caloric needs should be assessed to ensure the patient is not losing weight more than 10% of their usual body weight 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 Fluids needs can also double but the varies in each case based on the degree of the burn.

Macronutrient recommendations Con’t. Two important essential amino acids to burn recovery 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 Arginine stimulates growth hormone, which is required for wound healing . However more research needs to be conducted about the safety

Micronutrient recommendations Micronutrients are essential in endogenous antioxidant defense mechanisms and immunity Critically ill burn patients are at high risk of selenium, zinc, copper, vitamin C and vitamin E deficiency One study indicated that high-dose ascorbic acid infusion reduced resuscitation fluid requirements through an endothelial antioxidant mechanism

Micronutrient recommendations con’t Copper, selenium and zinc are key nutrients for wound healing and immune defense Copper is essential for wound repair Zinc is essential for wound healing Selenium is essential for the activity of glutathione peroxidase (GSHPx) Part of the body’s first line of antioxidant defense in both intra-and extracellular compartments

Micronutrient recommendations 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 Therefore, supplementation of these particular trace elements may be beneficial, but more research is needed

Conclusions 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. 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.