Practical guidelines for nutritional management of burn injury and recovery

doi:10.1016/j.burns.2006.06.014

Burns

Volume 33, Issue 1, February 2007, Pages 14-24

https://doi.org/10.1016/j.burns.2006.06.014 Get rights and content

Abstract

Nutrition practice in burn injury requires a multifaceted approach aimed at providing metabolic support during a heightened inflammatory state, while accommodating surgical and medical needs of the patient. Nutritional assessment and determination of nutrient requirements is challenging, particularly given the metabolic disarray that frequently accompanies inflammation. Nutritional therapy requires careful decision making, regarding the safe use of enteral or parenteral nutrition and the aggressiveness of nutrient delivery given the severity of the patient's illness and response to treatment. With the discovery that specific nutrients can actually alter the course of disease, the role of nutrition support in critical illness has shifted from one of preventing malnutrition to one of disease modulation. Today the use of glutamine, arginine, essential fatty acids, and other nutritional factors for their effects on immunity and cell regulation is becoming more common, although the evidence is often lagging. An exciting dichotomy exits, forcing nutrition support specialists to make responsible choices while remaining open to new potential helpful therapeutic options.

Introduction

Effective nutritional therapy in burn patients involves an understanding of the physiologic and metabolic alterations that accompany traumatic injury. Nutritional support must also accommodate the surgical and medical needs of the patient. The mode of therapy provided, such as route of administration and the aggressiveness of nutrient delivery depends on the severity of the patient's illness and response to treatment. Accordingly, nutritional objectives vary throughout the hospital course as the patient's clinical status changes. The following serves as a guideline for providing nutritional therapy to burned patients throughout the continuum of care. When possible, practice guidelines are evidence-based, however the myriad differences in approaches to burn care and the individual needs of patients preclude a rigid, inflexible approach to nutritional support in this population.

Section snippets

Determining nutritional status and nutrition risk

In burn patients, nutritional status is coupled to the stage of injury. Nutritional assessment consequently is a dynamic, ongoing process. At the time of admission, factors related to the patient's pre-burn history (including days post-burn, prior burn care and any complicating injuries), pre-injury height and weight, and clinical appearance serve as the basis for the patient's initial nutritional assessment. Patients who are malnourished (often those patients whose admission is significantly

Nutrition support strategies

Once energy and protein requirements are established, the mode of nutrient delivery that best meets both the metabolic and clinical needs of the patient is determined. Recognizing the importance of maintaining gut mucosal integrity, most clinicians opt to use enteral nutrition as the preferred mode of therapy [46]. In response, enteral feeding strategies have become increasingly sophisticated and enable considerable flexibility in the initiation, advancement, and composition of enteral

Summary and conclusion

Advances in infection control, early excision and grafting and aggressive nutritional support have greatly improved survival from severe burn injury. Critically ill burn patients are not homogenous. Their needs are complex and often condition specific. Many factors related to the clinical management of these patients, such as surgical needs, mechanical ventilation, and medication use influence nutritional status and the ability to feed a patient. With each change in clinical status,

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Cited by (106)

The efficacy of therapeutic interventions on paediatric burn patients’ height, weight, body composition, and muscle strength: A systematic review and meta-analysis
2024, Burns
To evaluate the efficacy of therapeutic interventions on pediatric burn patients’ height, weight, body composition, and muscle strength.
A systematic literature search was conducted in PubMed, Embase, and Web of Science up to March 2021. Eligible interventional studies reported metrics on the height, weight, body composition, or muscle strength of pediatric burn patients in a peer-reviewed journal. Meta-analyses were performed if ≥ 2 trials of clinical homogeneity reported on an outcome measure at the same time point post-burn.
Twenty-six interventional studies were identified, including twenty-two randomised controlled trials and four non-randomised trials. Most studies were conducted by a single institution. On average, the burn covered 45.3% ( ± 9.9) of the total body surface area. Three categories of interventions could be distinguished: rehabilitative exercise programs, pharmacologic agents, and nutrition support.
Each of the interventions had a positive effect on height, weight, body composition, or muscle strength. The decision to initiate an intervention should be made on a case-by-case basis following careful consideration of the benefits and risks. In future research, it is important to evaluate the heterogeneity of intervention effects and whether participation in an intervention allowed pediatric burn patients to reach the physical and functional status of healthy peers.
Higher serum prealbumin levels are associated with higher graft take and wound healing in adult burn patients: A prospective observational trial
2024, Burns
Nutritional support is essential in burn care. There are few studies investigating the effect of nutrition on burn healing. The purpose of this study was to determine the relationship between perioperative serum prealbumin levels and the probability of autologous skin graft take in burned patients.
A prospective observational study was carried out with burned adults recruited consecutively from April 2019 until September 2021. Serum prealbumin was determined perioperatively. The percentage of graft take was evaluated over the first 5 postoperative dressing changes. Time until full epithelialization (absence of wounds) was also registered.
A total of 60 patients were recruited, mostly middle-aged people with moderate flame burns. Serum prealbumin levels and graft take had a weak-moderate, nonlinear, statistically significant correlation. They were also an independent predictor of full epithelialization on the fifth dressing change, together with burn depth. Higher perioperative serum prealbumin levels were significantly associated with a reduction in time until full epithelialization.
Perioperative serum prealbumin levels are significantly correlated with the probability of split-thickness skin autograft take in burned patients and with a reduced time to achieve complete epithelialization. They were an independent predictor of full graft take.
Glutamine relieves the hypermetabolic response and reduces organ damage in severe burn patients: A multicenter, randomized controlled clinical trial
2022, Burns
Citation Excerpt :
During critical illness, body consumption exceeds synthesis, and supplementation with exogenous glutamine is an appropriate choice [15,16]. Therefore, the clinical nutrition guidelines in various countries recommend that burn patients should be given glutamine [17–20]. Currently, the pharmacological efficacy of glutamine in maintaining intestinal mucosal integrity has been recognized [14,21,22].
Severe burns can cause a hypermetabolic response and organ damage. Glutamine is a conditionally essential amino acid with various pharmacological effects. In this study, whether glutamine could alleviate the hypermetabolic response and maintain organ function after burn injury was analyzed.
A multicenter, randomized, single-blind, parallel controlled trial was conducted to evaluate the efficacy of glutamine in decreasing hypermetabolism after burn injury. Physiological and biochemical indexes, such as vital signs, metabolic hormones, metabolic rate, and organ damage, were recorded on the 7th and 14th days after treatment.
In total, 55 adult burn patients with a total burn surface area (TBSA) of 30–70% were included in this study and randomly divided into the burn control (B, 28 patients) and burn+glutamine (B+G, 27 patients) groups. Except for the glutamine administration, the groups did not differ in the other treatments and nutrition supplements. The levels of diamine oxidase (DAO), lactulose/mannitol (L/M), β₂-microglobulin, lactate dehydrogenase (LDH), hydroxybutyrate dehydrogenase (HBD) and cardiac troponin l (cTnl) in the B+G group were significantly lower than those in the B group (p < 0.05 or 0.01). The levels of resting energy expenditure (REE), serum catecholamines, glucagon, lactate and Homeostasis model assessment (HOMA) in the B+G group were significantly lower than those in the B group (p < 0.05 or 0.01). No significant difference was found in the length of hospitalization or the mortality rate between the two groups (p > 0.05).
Glutamine moderately alleviates the hypermetabolic response and reduces organ damage after severe burns. Therefore, the early application of glutamine, which is effective and safe, should be used as an active intervention as early as possible.
Validation of the modified NUTrition Risk Score (mNUTRIC) in mechanically ventilated, severe burn patients: A prospective multinational cohort study
2021, Burns
Whether nutrition therapy benefits all burn victims equally is unknown. To identify patients who will benefit the most from optimal nutrition, the modified Nutrition Risk in Critically Ill (mNUTRIC) Score has been validated in the Intensive Care Unit. However, the utility of mNUTRIC in severe burn victims is unknown. We hypothesized that a higher mNUTRIC (≥5) will be associated with worse clinical outcomes, but that greater nutritional adequacy will be associated with better clinical outcomes in patients with higher mNUTRIC score.
This prospective study included data from mechanically ventilated, severe burn patients (n = 359) from 51 Burn Units worldwide included in a randomized trial. Our primary and secondary outcomes were hospital mortality and the time to discharge alive (TTDA) from hospital. We described the association between nutrition performance and clinical outcomes.
Compared to low mNUTRIC (n = 313), the high mNUTRIC group (n = 46) had higher mortality (61% vs. 19%, p = 0.001), and longer TTDA (>90 [87–>90] vs. 64 [38–90] days, p = <0.0001). Only in the high mNUTRIC group, increased calorie intake (per 20% increase) was associated with lower mortality and a faster TTDA.
The mNUTRIC score identifies those with poor clinical outcomes and may identifies those mechanically ventilated, severe burn patients in whom optimal nutrition therapy may be more advantageous.
Evaluation of high protein intake to improve clinical outcome and nutritional status for patients with burns: a systematic review
2021, Burns
Patients with severe burns undergo a local and systemic response to the injury. As part of this response the patient becomes hypermetabolic. Current guidelines advise high protein intakes to counteract the catabolic response to burns, but this appears to be based on minimal experimental evidence. Hence the aim of this review was to examine the evidence for improvements in nutritional status and clinical outcome with the administration of high protein intakes for patients with burns.
Eight databases were searched for clinical trials with burn patients receiving two or more levels of protein intake at or above the level recommended for healthy individuals (0.75 g/kg/d) and presenting results for at least one of the following pre-defined outcomes: nitrogen balance, length of stay, weight change, survival, physical therapy index, protein fractional synthetic rate, immunological measurements, bacteraemic days, systemic antibiotic days and net protein synthesis.
Six studies were included, 4 of which were randomized trials. All had major methodological limitations, in particular none was blinded. There was too much heterogeneity in study design, patient characteristics and the timing and magnitude of the interventions to justify formal meta-analysis. There was no reliable evidence of improvement in nitrogen balance, but there was some evidence of increased weight gain on higher protein diets. One small study reported an increase in survival and significant improvements in infection rates and some indicators of immune function in children. Length of stay was not significantly improved. There was weak evidence of an improvement in muscle strength and endurance but no significant increase in protein synthesis in muscle or skin, or net protein synthesis in the whole body.
There is currently only very weak evidence to justify administering high protein diets to patients following burns.
Safety and efficacy of intraoperative gastric feeding during burn surgery
2019, Burns
Citation Excerpt :
Overall intensive care unit and in-hospital mortality are also decreased significantly [5]. Guidelines from multiple societies including the International Society for Burn Injury (ISBI), Society of Critical Care Medicine (SCCM), and both the American and European Societies for Parenteral and Enteral Nutrition (ASPEN and ESPEN) all recommend nutritional support for patients with greater than 20% total body surface area (TBSA) burns [6–8]. EN should be initiated early in the patient’s hospital course, preferably within the first 24 h, and then advanced to a goal rate.
Large burns are associated with a dramatic increase in metabolic demand, and adequate nutrition is vital to prevent poor wound healing and septic complications. However, enteral nutrition (EN) support is frequently withheld perioperatively, risking nutritional deficits. We retrospectively examined the safety and feasibility of continuing EN during surgery in patients with an established airway, and estimated the impact of perioperative fasting on overall caloric intake.
Mechanically ventilated patients admitted to our urban, verified burn center between January 2012 and July 2017 with greater than 20% total body surface area (TBSA) burns were included in this retrospective analysis. The total volume of EN received by the patient during each 24-h period and goal EN volume as determined by a clinical dietitian were collected.
A total of 45 patients met criteria with mean TBSA of 44% (range 20–84%). Most patients had a gastric feeding tube (86%). Each patient underwent a median of 4 operations (range 1–33) for a total of 249 operative days and 991 non-operative days. There were no aspiration events. On non-operative days, patients met 85% of estimated caloric needs. EN was held on 170 operative days (69%), and on these days, only 34% of total caloric needs were met. EN was continued on 77 operative days (31%), and on these days, 95% of total caloric needs were met (p < 0.001). Patients who had EN held for at least 50% of operative procedures (n = 30) met only 69% of caloric goals while intubated. By comparison, patients who had EN continued for a majority of procedures (n = 15) met 81% of caloric goals (p = 0.002).
Continuing EN intraoperatively in patients with an established airway appears to be a safe and efficacious way to meet patients’ nutritional needs, including when feeding is delivered via a gastric route. This is particularly important given that placement of nasojejunal feeding tubes can be difficult, particularly in resource-poor settings where endoscopic or fluoroscopic-guided placement may not be practical.

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ReviewPractical guidelines for nutritional management of burn injury and recovery

Abstract

Introduction

Section snippets

Determining nutritional status and nutrition risk

Nutrition support strategies

Summary and conclusion

Surgery

J Am Diet Assoc

JADA

Am J Clin Nutr

Metabolism

Metabolism

Metabolism

Metabolism

J Am Diet Assoc

Metabolism

Surgery

Am J Surg

Lancet

Am J Clin Nutr

Chest

Burns

Am J Surg

Nutrition

Nutrition

Surgery

Burns

Am J Clin Nutr

Early burn center transfer shortens the length of hospitalization and reduces complications in children with serious burn injuries

J Burn Care Rehabil

Refeeding of the severely malnourished burn patient

Proc Am Burn Assoc

Sequential metabolic changes following induction of systemic inflammatory response in patients with severe sepsis or major blunt trauma

World J Surg

Determinants of skeletal muscle catabolism after severe burn

Ann Surg

Increased rates of whole body protein synthesis and breakdown in children recovering from burns

Ann Surg

Nutritional support in AIDS

Am J Gastroenterol

Evaluation of serum visceral protein levels as indicators of nitrogen balance in thermally injured patients

JOEN

The prognostic value of nutritional and inflammatory indices in patients with burns

JBCR

Inaccuracy of nitrogen balance determinations in thermal injury with calculated total urinary nitrogen

J Burn Care Rehabil

Protein loss across burn wounds

J Trauma

Albumin kinetics in hypoalbuminemic patients receiving total parenteral nutrition

J Parenter Enteral Nutr

The role of visceral proteins in the nutritional assessment of intensive care unit patients

Curr Opin Clin Nutr Metab Care

Pre-albumin and C-reactive protein are predictive of nutritional adequacy in burned children

JBCR

Energy and protein provisions revisited: an outcomes-based approach for determining requirements

JBCR

The metabolic response to stress: an overview and update

Anesthesiology

Influence of glucose kinetics on plasma lactate concentration and energy expenditure in severely burned patients

J Trauma

Glucose requirements following burn injury. parameters of optimal glucose infusion and possible hepatic and respiratory abnormalities following excessive glucose intake

Ann Surg

Inhibition of muscle glutamine formation in hypercatabolic patients

Clin Sci (Lond)

Arginine and ornithine kinetics in severely burned patients: increased rate of arginine disposal

Am J Physiol Endocrinol Metab

Sequential changes in the metabolic response in critically injured patients during the first 25 days after blunt trauma

Ann Surg

The effect of staged burn wound closure on the rates of heat production and heat loss of burned children and young adults

J Trauma

The effect of occlusive dressings on the energy metabolism of severely burned children

Ann Surg

The effect of burn wound size on resting energy expenditure

J Trauma

The effect of burn wound excision on measured energy expenditure and urinary nitrogen excretion

J Trauma

Review
Practical guidelines for nutritional management of burn injury and recovery