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Medical Nutrition Therapy: Burn Patients

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1 Medical Nutrition Therapy: Burn Patients
Amy Gabrielson

2 Objectives Be able to classify different types of burns and their severity. Be able to understand how burns affect the body. Identify the medical treatments for burn patients. Identify the medical nutrition therapy for burn patients and its importance to the patient. Be able to understand the ethical issues that accompany burn victims.

3 Causes of Burns Burns result from physical exposure to:
heat, chemicals, radiation or electricity Injury affects the skin and in some cases muscle and bone. Severity of the burns is classified by how deep the burn penetrates the body. Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education.

4 Burn Exposure Thermal Exposure- Direct contact with a heat source
i.e. hot water, flames Most common and commonly occur in the home or workplace Chemical Exposure Coming into contact with chemicals that cause a reaction on the body. Thermal Exposure- Most common type of burn is thermal burns from water or flames. Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education.

5 Burn exposure cont… Electrical Exposure
An electrical current moves through the tissue Severity correlates with voltage, location of contact and amount of time exposed Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education.

6 “Medical treatment is required for more than1
“Medical treatment is required for more than1.1 million burn victims each year with approximately 45,000 hospitalizations.” 1 “Mortality rate from burns has declined significantly over the previous several decades due to major advances in medical care.”2 1 National Institute of General Medical Sciences. Trauma, Shock, Burn and Injury: Facts and Figures. Bethesda (MD): National Institute of General Medical Sciences, National Institute of Health. Available from: 2Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education.

7 Burn Classifications Superficial (First Degree)
Top layer of epidermis- sunburn Partial Thickness (Second Degree) Destruction of the epidermis and dermis Full Thickness (Third & Fourth Degree) Destroys all layers of skin and can involve underlying muscle, organs and bones. Superficial Burns of First degree burns are burns to the top layer of skin called the epidermis. Typically a bad sun burn and can be treated by outpatient care. Partial thickness involves the destruction of the epidermis and the dermis layers of skin. Blistering, and redness occurs and needs medical attention. Full thickness burns are third degree when all layer of skin have been burns and become fourth degree when muscle, organ and bones are burned as well. This type of burn requires immediate medical attention. Morgan ED, Bledsoe SC, Barker J. (2000). Ambulatory management of burns. Am Fam Phys. 62: Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education.

8 Medline Plus (2009) www.nlm.nih.gov/.../ency/fullsize/1078.jpg

9 Rule of 9’s Makes estimation of body surface area (BSA) affected by burns. Helps assess the extent of the burn and helps provide basis for prescribing fluid and medication. Both arms equal 9%. One leg equals 9%. Chest equals 9%. Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education. Monstrey, S, Hoeksema, H, Verbelen, J, Pirayesh, A, Blondeel, P. (2008). Assessment of burn depth and wound healing potential. Burns. 34:

10 Assessment of Burn Depth
Burn depth needs to assessed to determine treatment goals and actions. Surgeons need to know burn depth to assess potential for scarring. Thermal imaging, Vital Dyes and Laser Doppler imaging Thermal imaging is a measurement of burn wound temperature. Deeper wounds tend to show colder temperatures than superficial burns because there is less vascular perfusion or blood flow near the wound surface. Full thickness burns will have a temp 2 degrees lower than unburned skin and is 90% accurate. Vital Dyes identify surface necrosis of the skin but may not necessarily show the difference between partial and full thickness burns. Not generally used. Laser Doppler imaging uses laser lights to assess the blood flow in a sample tissue and then compare that flow frequency to the frequency in the burn tissue. It is 92% effective but show adverse effects such as cause addition burns by using a heated probe. The heated probe also causes pain and discomfort to the patient. Monstrey, S, Hoeksema, H, Verbelen, J, Pirayesh, A, Blondeel, P. (2008). Assessment of burn depth and wound healing potential. Burns. 34:

11 Effects of Burn on the Body
Extensive inflammatory response Rapid fluid shifts and accumulation. Hypermetabolic state Muscle protein catabolism Decrease cardiac output because of increased capillary permeability and vasodilation. Heat loss Increased blood glucose levels Burn Shock Potts, N.L., Mandleco, B.L. (2007). Pediatric Nursing: Second Edition. New York: Thomson Delmer Learning.

12 Goal of Medial Treatment
Prevent tissue necrosis Maintain global tissue perfusion Prevent infection Reduce scarring

13 Medical Treatment Topical Agent- Prevents Infection
Silver Sulfadiazine cream, Silver Nitrate Clean wound dressings Some wounds require skin grafting Requires multiple surgeries Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education.

14 Nutrition Therapy Goals
Promote wound healing Maintain lean body mass Restore fluid levels

15 Fluid Therapy Need for fluid resuscitation to maintain global tissue perfusion. Parkland Formula is used to calculate the amount of fluid to use to resuscitate the patient based on burn percentage. 4mL/kg/% burn in the first 24 hrs, half of which is given in the first 8 hours Be careful not to over resuscitate in fear or burn edema. Vitamin C and Vasopressin help reduce fluid requirements Fluid Therapy is a necessary part of burn therapy. It is important for the RD to understand what the physician’s goal are for fluid therapy so that a diet plan can be monitored accordingly. Fluid resuscitation is necessary for the maintenance of tissue perfusion. To calculate the amount of fluid needed for the patient, the parkland formula is used. 4mL/kg/% of burn for the first 24 hours. Half of which should be given in the first 8 hours of initial burn. Over resuscitation may be an issue causing burn edema in patients. Vitamin C and vasopressin may be used to control edema and reduce fluid requirements. Tricklebank, S. (2009). Modern trends in fluid therapy for burns. Burns. 35:

16 Hypermetabolism Catecholamines, cortisol, and other glucocorticoids are increased in burn victims due to the stress state of the body causing a hypermetobolic response. Epinephrine and norepinephrine increase 10-fold in people with burns greater that 30-40%. Hypermetabolic state lasts 9-12 months after a burn. Initial reaction for burn victims is a fight or flight, stress reaction. Catecholamines, cortisol and other glucocorticoids are increased due to the stress. The release of catecholamine triggers the hypermetabolic response. Catecholamine increases heart rate and blood pressure, shifts glucagon from the liver, and increases lipolysis. Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition. 25:

17 Glucose Metabolism Accelerated gluconeogenesis, glucose oxidation and plasma clearance of glucose Blood glucose levels increase due to insulin resistance and breakdown of glycogen stores Glucagon excretion by the liver increases initially after the burn and slows down as wound heals Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition. 25: Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10: Potts, N.L., Mandleco, B.L. (2007). Pediatric Nursing: Second Edition. New York: Thomson Delmer Learning. .

18 Muscle Protein Catabolism
Protein catabolism increases in burn patients leading to protein losses of 260 mg protein/kg/hr. Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:

19 Nutrition Therapy Always prefer oral intake if possible
Preserves GI function Food has therapeutic qualities that tube feedings do not If a patient cannot consume 80% of estimated caloric or protein needs, enteral feeding is needed TPN may be contraindicative because of infection but should be used if necessary First step in assessing nutrition care is determine is oral care is appropriate. Natural digestion is preserved when eating orally. Consuming food provides micro- and macronutrients as well as phytochemicals and antioxidants. Nutrients and phytochemicals from food aid in wound healing and overall health of the patient. Enteral feeding is initiated when 80% of caloric and protein needs cannot be met. An appropriate step may be to administer night feedings so that appetite and oral intake during the day can be stimulated. Early administration of a feeding tube has shown positive effects on wound healing and diminishing gut bacterial translocation. TPN is the last option for nutritional support. If no other means is acceptable, TPN may be administered. Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:

20 Table 1: Nutrition Support for Burn Injuries
Table 1 Use of the modified Harris-Benedict equations to estimate resting energy expenditure Men: BEE=( W+5.0H-6.76A)x(Activity Factor)x(Injury and/or Burn Factor) Women: BEE=( W+1.85H-4.68A)x(Activity Factor) x(Injury and/or Burn Factor) W=weight in kg; H=height in cm; A=age in years. Stressors Stress Factors Activity factor Confined to bed 1.2 Out of bed 1.3 Injury factor Minor operation Skeletal trauma Major surgery 1.4 Sepsis 1.6 Burn factor Stress Factors 20% TBSA 1.2 20–25% TBSA 1.6 25–30%TBSA 1.7 30–35% TBSA 1.8 35–40% TBSA 1.9 40% TBSA 2.0 Because of hypermetabolism and being in a high stress state, burn victims need higher energy requirements. Harris Benedict is an option to use which takes into account stress factors and percentage of burns. Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:

21 Protein Requirements Amino acids are important for collagen synthesis for wound healing Maintaining visceral protein is important for organ function especially for immune systems Maintaining intercostal muscles and the diaphragm is imperative for respiratory efficiency g/kg protein requirement for burns Urinary nitrogen losses increase with severity of the burn injury Trauma patient may lose g of lean body nitrogen daily Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:

22 Protein Requirement cont…
Protein requirement estimate: Combine 24-hour urinary nitrogen loss, 2 to 4 g of nitrogen for fecal loss and 4 to 5 g/d for anabolism. Convert each gram of nitrogen to 6.25 g of protein. Patients are likely to miss feedings if in surgery frequently so should be given high protein formulas between surgeries Be aware of uremia- increase free water Generally 20-25% of calories from protein Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:

23 Lipid requirements Lipid stores are critical for long-term fuel after major thermal burns Fat oxidation is higher in hypermetabolic patients than in normal patients Fat consumption should not exceed 30% of the diet to avoid diarrhea Beneficial because Fat is a more concentrated form of energy Vegetable oils contain essential fatty acids and fat soluble vitamins Help with infection Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:

24 Lipid Study A randomized study of 43 adolescent and adult burned patients were administered a low-fat diet (15% total calories from fat) Administered enterally of parenterally Less pneumonia, improved respiratory function, faster nutritional status and shorter length of care was found in comparison to a high fat diet of 35% of calories from fat Recommended 12-15% of calories to be lipids Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition. 25: Garrel D.R, Razi M, Lariviere F, Jobin N, Naman N, Emptoz-Bonneton A, et al. (1995) Improved clinical status and length of care with low-fat nutrition support in burn patients. JPEN 19:482-91

25 Carbohydrate Requirements
Carbohydrate metabolism is significantly affected in burn patients Gluconeogenesis from Alanine and other AAs are elevated Carbohydrates are good sources for protein sparing especially for nitrogen retention High carbohydrates can contribute to hyperglycemia in which case a diet can be altered to increase fat in the diet Recommended 60% of the calories from CHO, not surpassing 400g/d or1600 kcal/d Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition. 25: Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:

26 Assessing Nutritional Status
Pre-Albumin and Albumin for protein status Pre-Albumin 15 mg show malnutrition <10mg/dl- Deficient Albumin <3.0mg/dl- Deficient Weight loss of 5% in 30 days=Malnutrition Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition. 25:

27 Vitamin C Needed for edema prevention
Involved in collagen synthesis for wound healing Aid in immune functioning Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition. 25:

28 Vitamin A Needed for immune function Epithelialization
5000 IU of Vitamin A per 1000 cal of enteral feeding is recommended Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition. 25:

29 Vitamin D and Calcium Burns cause an impairment in the metabolism of Vitamin D Burn patients are more susceptible to fractures so calcium and vitamin D should be administered Calcium mg daily Vitamin D IU daily Maintain serum 25-hydroxy vitamin D level of 30-60 ng/Ml Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition. 25:

30 Zinc and Copper Zinc and copper deficiencies have been seen in burn patients most likely from tissue breakdown and urinary excretion. Supplementation is recommended for patients Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition. 25:

31 Ethical Issues The quality of care and the recovery of burn patients depend on the amount of effort the healthcare providers put into the patient. Quality of life

32 Summary Burns result from thermal, chemical and electrical sources
Burns are classified as Superficial, Partial thickness and Full-thickness Rule of 9’s for BSA % Burns cause a inflammatory, stress response affecting many bodily systems Protein is essential for wound healing Vitamins and Minerals supplements are neccesary

33 Questions? Thank you 


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