ReviewPractical guidelines for nutritional management of burn injury and recovery
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,
References (95)
- et al.
Sodium bromide by instrumental neutron activation analysis quantifies change in extracellular water space with wound closure in severely burned children
Surgery
(2003) - et al.
Prediction of total urinary nitrogen from urea nitrogen for burned patients
J Am Diet Assoc
(1985) - et al.
Urinary urea nitrogen is imprecise as a predictor of protein balance in burned children
JADA
(1997) Herman award lecture, 1996: relation of metabolic studies to clinical nutrition—the example of burn injury
Am J Clin Nutr
(1996)- et al.
Glucose metabolism in severely burned patients
Metabolism
(1979) - et al.
Quantitative contribution by skeletal muscle to elevated rates of whole-body protein breakdown in burned children as measured by N-methylhistidine output
Metabolism
(1978) - et al.
Regulation of glucose kinetics in trauma patients by insulin and glucagon
Metabolism
(1992) - et al.
Plasma arginine and leucine kinetics and urea production rates in burn patients
Metabolism
(1995) - et al.
Dietary requirements of patients with major burns
J Am Diet Assoc
(1974) - et al.
Urea and protein metabolism in burned children: effect of dietary protein intake
Metabolism
(1997)
Persistence of muscle catabolism after severe burn
Surgery
Intrahepatic cholestasis with parental alimentation
Am J Surg
Postoperative enteral versus parenteral nutrition in malnourished patients with gastrointestinal cancer: a randomised multicentre trial
Lancet
Calorie and protein provision for recovery from severe burns in infants and young children
Am J Clin Nutr
Caloric intake in medical ICU patients: consistency of care with guidelines and relationship to clinical outcomes
Chest
Impact of duodenal feeding on the oxygen balance of the splanchnic region during different phases of severe burn injury
Burns
Non-occlusive bowel necrosis occurring in critically ill trauma patients receiving enteral nutrition manifests no reliable clinical signs for early detection
Am J Surg
Effects of total parenteral nutrition on endotoxin translocation and extent of the stress response in burned rats
Nutrition
Effect of intravenous omega-6 and omega-3 fat emulsions on nitrogen retention and protein kinetics in burned rats
Nutrition
Short-term enteral glutamine does not enhance protein accretion in burned children: a stable isotope study
Surgery
Cutaneous copper and zinc losses in burns
Burns
Exudative mineral losses after serious burns: a clue to the alterations of magnesium and phosphate metabolism
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
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Glutamine relieves the hypermetabolic response and reduces organ damage in severe burn patients: A multicenter, randomized controlled clinical trial
2022, BurnsCitation 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].
Safety and efficacy of intraoperative gastric feeding during burn surgery
2019, BurnsCitation 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.