Burns 31 (2005) 5559

www.elsevier.com/locate/burns

Caloric requirements in patients with necrotizing fasciitis$

Caran Graves*, Jeffrey Saffle, Stephen Morris, Theresa Stauffer, Linda Edelman
Intermountain Burn Center, University of Utah Health Sciences Center, Salt Lake City, UT, USA
Accepted 13 July 2004

Abstract
Patients with necrotizing fasciitis (NF) and other soft tissue infections are often treated in burn centers due to the extent of wound care and
surgical intervention needed. Sepsis and surgery increase metabolic needs and may limit oral intake and necessitate enteral (TEN) or
parenteral (TPN) nutrition. We reviewed the records of patients admitted with necrotizing fasciitis or surgical soft tissue infections from
January 1993 to June 1998 who had indirect calorimetry (IC) measurements performed. Records were also reviewed for surgical/medical
management and nutritional intervention.
Twenty-six patients were admitted with 17 of these having IC measurements (133 total IC measurements). The IC group had more
surgeries (mean 4.9 versus 2.7) and 82% required mechanical ventilation (mean 17.9 days). Energy expenditure showed a moderate but
significant increase in energy needs (mean 23.8 kcal/kg/day, 124% BEE) with large variations (10.742.4 kcal/kg/day, 60%199% BEE) in
individual energy requirements. Caloric intake averaged 73% of needs based on IC (range 53%104%). Nearly all patients (94%) required
TEN (82%) and/or TPN (41%) nutrition for a mean of 24 days (range 168 days).
NF presents a broad range of metabolic and surgical needs. Our data indicates patients with NF have increased energy requirements and
suggests provision of calories at 124% basal or 25 kcal/kg actual wt/d; but due to the large individual variation, routine assessment using IC is
recommended. Clinicians need to recognize the likely need for nutritional support and possibly lengthy clinical course for these patients.
# 2004 Elsevier Ltd and ISBI. All rights reserved.
Keywords: Calorimetry; Energy metabolism; Nutrition requirements; Necrotizing fasciitis; Surgical soft tissue infection

1. Introduction
Necrotizing fasciitis (NF) is an invasive, rapidly
progressing, soft tissue infection producing necrosis at the
fascial level and may also involve overlying tissue or
underlying muscle [14]. Early descriptions from the Civil
War referred to infections associated with penetrating
injuries as hospital gangrene [5]; in recent years, the term
necrotizing soft tissue infections has been suggested to
encompass these entities[4,5]. NF also includes Fourniers
gangrene which involves the perineal region.
$
Presented in part at the American Burn Association Annual Meeting,
April 1821, 2001, Boston, MA.
* Corresponding author. Present address: Nutrition Care Service, University of Utah Hospitals and Clinics, 50 N. Medical Dr., Salt Lake City, UT
84132. Tel.: +1 8015812656; fax: +1 8015852554.
E-mail address: caran.graves@hsc.utah.edu (C. Graves).

0305-4179/$30.00 # 2004 Elsevier Ltd and ISBI. All rights reserved.

doi:10.1016/j.burns.2004.07.008

NF results in high mortality rates reported from 30% [1,6]

to 70% [5], and is commonly associated with sepsis [6]. In
addition, many patients present with pre-existing conditions
which make medical management more challenging and
which may contribute to morbidity and mortality [1,6,7].
Reported risk factors include diabetes, peripheral vascular
disease, obesity, malnutrition, and immunosuppression.
Treatment focuses on rapid and thorough debridement of
the affected area, often requiring multiple surgical procedures, along with antibiotic coverage and intense medical
management. Numerous studies documenting the causes,
co-morbid factors, treatment and outcomes exist in the
published literature, as have many detailing the effect both
sepsis and surgery can have on metabolism and nutritional
needs. However, few studies have mentioned the need for
nutritional intervention and support [1,6,8]. These studies
have limited their comments to reporting that patients
received nutritional support, with few details as to type or

56

C. Graves et al. / Burns 31 (2005) 5559

amount of that support. The nutritional requirements of

patients with NF have not been clearly described. The
current study retrospectively reviewed patients with NF
admitted to a Burn/Trauma center in order to evaluate the
nature and extent of nutritional needs and interventions.

2. Patients and methods

This study was conducted with the approval of the
Institutional Review Board of the University of Utah
Medical Center. We reviewed the records of patients
admitted to our burn center for acute treatment of NF from
January 1993 through June 1998. We recorded medical and
surgical data including age, number of surgical procedures,
length of stay (LOS) in days, mechanical ventilation (days),
pre-existing conditions, outcomes and disposition. Nutritional assessment data included measured admit weight,
percent of calculated ideal weight, estimated basal energy
expenditure (HBEE Harris-Benedict equation using actual
body) [9], and type and duration of nutritional support.
Patients on nutritional support had IC measurements two to
three times per week per unit protocol. For those with IC
measurements we recorded resting energy expenditure
(REE) without correction factors. These measurements
were analyzed to assess the degree of hypermetabolic
response (as percent of HBEE) they exhibited. SPSS for
Windows, version 11 (SPSS Inc, Chicago, IL) was used for
statistical analysis; data is presented as mean  S.D.
2.1. Nutritional support
We treated all patients admitted to the burn center with a
standard protocol for nutritional support. On admission, we
placed naso-enteric feeding tubes in those patients who
required ongoing mechanical ventilation and whom we felt
would be unable to eat a satisfactory diet. Total parenteral

nutrition (TPN) was used only if patients were unable to be

fed enterally; in these cases we continued low volume enteral
feeds as tolerated, and switched to full enteral nutrition
whenever possible. Enteral nutrition was provided with a
high protein formula, RepleteTM (Nestle, Deerfield, IL).
We routinely measured energy expenditure in all patients
by performing IC two to three times a week, using a
Deltatrac Metabolic Cart (Sensormedics, Anaheim, CA).
The metabolic cart was calibrated to local barometric
pressure, ambient O2/C02 and to a calibrated gas mixture of
95% O2 and 5% CO2 prior to use.
In each patient, respiratory therapists measured oxygen
consumption (VO2), CO2 production (VCO2), and REE and
RQ in the early morning before patients had begun daily
activities. Due to clinical status (i.e. symptoms consistent
with sepsis syndrome), patients were generally sedated,
intubated, and receiving analgesics during IC. Resting
energy expenditure was recorded when measurements were
stable for at least 10 min. Patients on TEN or TPN had
feedings continued at a steady rate throughout each
measurement; patients on oral diets were measured before
breakfast, after an overnight fast.

3. Results
We reviewed the medical records of 26 patients admitted
during the study period with NF. Seventeen patients,
including all those on nutrition support, had at least one
IC measurement and form the analysis group; this subset is
compared to those without IC measurements in Table 1.
Patients with IC measures were similar to the larger group in
age, admit weight, LOS and estimated HBEE, but differed
significantly in the number of surgical procedures, ventilator
nutrition support days (P < .05, MannWhitney U test).
There were three deaths. Nearly half of the survivors were
discharged directly home, with the others transferring to a

Table 1
Comparison of patients with indirect calorimetry measurements to all patients admitted with necrotizing fasciitis
Calorimetry (n = 17)

No calorimetry (n = 9)

Sex
Age (year)
Wt.% ideal wt.
Range

53% male
52.3  14 range 3381
149%  60%
88%330%

78% male
50.0  16.3 range 2473
135%  78.7%
64%332%

Co-morbid
DM
HTN/CAD
Obese (>120% IBW)
LOS days
Nutrition support days
Surgery
Range
Vent
Vent days
Vent range
HBEE

59%
47%
65%
35.2  18.8 days
24.2  20.4 days* (16/17 patients)
4.9  2.8*
215
82% (14/17)
17.9  17.9 days*
065 days range
1900  486 kcal/day

44%
33%
11%
21  12.0
3  9*
2.7  1.7*
15
22.2% (2/9)
0

P < .05.

1865  738

C. Graves et al. / Burns 31 (2005) 5559

57

Table 2
Nutritional profile based on indirect calorimetry measurements (17 patients)
a

Average energy expenditure

Minimum energy expenditureb
Maximum energy expenditureb
REE kcal/kg/daya
Days on nutrition supportc
Average intake (% REE)a
a
b
c

Mean  S.D.

Range

124.3  31.5
108.6  25.7%
140.7  40.6%
23.8  8.1
24.2  20.4
73.2  15.7%

60%199%
60%140.3%
64.1%199%
10.742.4
168
52.9%104.1%

Expressed as % of BEE using HB equation; n = 133.

Expressed as % of BEE using HB equation; n = 17.
Of those on nutrition support; n = 16.

Table 3
Comparison of initial, maximum and overall resting energy expenditure

Day post
Admit
Range
MEE
%HB MEE
Range

Initial IDC (n = 17)

IDC max n = 17

5.2  4.2 days

215 days

11.9  4.1 days

231 days

2337.8  497.3 kcal

129.7  38.9%
64.1%183.4%

2576.6  654
140.7  40.6%
64.1%199.4%

Total n = 133

2372  575
124.3  31.5
60%199.4%

rehabilitation or skilled nursing facility (Tables 2 and 3).

Those transferred to another facility had longer LOS and
were more likely to have been ventilated than those discharged home (70% versus 25%) and most (70%) remained
on enteral nutrition support at the time of transfer (Table 4).
3.1. Indirect calorimetry group
In the 17 patients who had IC performed, there were 133
total IC measurements for a mean of 7.8 measurements per
patient (range 125). The mean REE of 124.3  31.5% BEE
differed significantly from HBEE (P < .01, Table 2).
However, there was a correlation between REE and HBEE
(r(131) = 0.314, P < .001). RQ values were available for 123
IC measurements and averaged 0.837  0.11 (range 0.6
1.1). Daily REE ranged from 60% to 199% of estimated
HBEE. The two cases shown in Figs. 1 and 2 illustrate the
wide variability of calorie needs for individual patients.
As shown in Table 2, initial measurements (post-admit
day 5  4.2) were similar to the overall average; maximum
REE generally occurred on post-admit day 11.9  4.1 with
energy needs of 140.7% HBEE (2576.6  654 kcal/d).
Initial IC and maximum measures also differed from HBEE
but showed no correlation (P < .05).

Fig. 1. Measured calorie needs (IC () and average IC ()) and intake
(actual (. . .) and mean (
)) in a 50-year-old woman with NF of the
perineum requiring a temporary diverting colostomy. Other problems
included respiratory distress and sepsis syndrome and her past medical
history included hypertension and obesity (admit wt. 189 kg = 164% ideal
wt.). She received both enteral and parenteral nutrition support. She underwent surgery on hospital days 1, 7, 19, 36 and was transferred to a skilled
nursing facility on hospital day 70. Oral intake started on day 66 with TEN
continuing at discharge.

All patients in this group underwent surgical intervention

(mean 4.9  2.8; range 214). Eighty-two percent required
mechanical ventilation for a mean of 17.9  17.9 days. The
majority (60%) received blood products. LOS averaged 35.2
 18.8 days, with ventilated patients remaining hospitalized
35.9  20.2 days versus 19.0  7.6 days for non-ventilated
patients (P < .05; MannWhitney U test).
Many patients were overweight upon admission, averaging 149% of ideal body weight, although 29% were at
or below ideal weight. Sixteen patients (94%) required
either TEN (n = 14) and/or TPN (n =7) nutrition for a mean

Table 4
Patient outcomes
All patients (n = 26)
Mean  S.D. (%)
Mortality
LOS
Discharged home
Rehab/SNF

3 (11.5%)
26.4  16.9
11 (42%)
12 (46%)

IC patients (n = 17)
Range
366

Mean  S.D.
2 (8.8%)
35.2  18.8
7 (41%)
7 (41%)

Range
1470

Fig. 2. Measured calorie needs (IC () and average IC ()) and intake
(actual (. . .) and mean (
)) in a 47 year old man with Fourniers gangrene
and no significant past medical history; he weighed 86.4 kg (114% ideal
wt.). He underwent surgery on hospital days 1, 2, 7, 14 and 17 and received
enteral nutritional support for 33 days. He advanced to all oral intake prior to
discharge home on day 37.

58

C. Graves et al. / Burns 31 (2005) 5559

of 24.2  20.4 days. All but one ventilated patient

(ventilated three days) received supplementary nutrition.
Most patients (76%) started TEN/TPN within two days of
admission. Caloric intake while on TEN/TPN (n = 16)
averaged 73.2% of REE (range 52.9%104.1%) with only
five patients (31%) receiving >85% REE. Examples of
HBEE, REE and actual intake are shown in Figs. 1 and 2.

4. Discussion
The group of patients reviewed here had a mortality rate
lower than that often reported for NF, although surgery rates
were consistent with a previous study from our unit. [10]
A large percentage of patients required multiple surgical
procedures, mechanical ventilation, blood products and
nutritional support.
Surgical texts often note a high incidence of obesity and
DM in patients with NF [2]. While a slight majority of our
patients had body weights greater than 120% of ideal (54%
of total and 65% of IC group), many did not, and nearly a
third (29%) were at or below ideal weight. Most estimates of
energy needs include weight which may lead to misestimation of calorie needs with extremes of body weight
such as obesity [11,12]. While several modifications have
been suggested to better estimate energy needs, the use of
adjusted weight is controversial [12] and, as such, we
chose to use actual weight for HBEE. Due to the large
number of obese patients, actual body weight may have
overestimated HBEE and, therefore, lowered the calculated
degree of hypermetabolism (REE/HBEE).
Clinicians have long recognized that metabolic stress
such as injury or sepsis increases energy needs above normal
basal requirements [1315]. Attempts to estimate those
needs in order to provide adequate nutrition has resulted in
numerous equations, many using HBEE for basal estimates.
Sick, hospitalized patients rarely meet the criteria for
estimating basal needs accurately and, as a result, many
variations and correction factors have been published
[14,15]. In addition, clinicians often provide additional
calories for multiple stressors (e.g. fever and fracture) and
for activity [16,17].
As IC became more widely available, many studies were
published suggesting that standard formulas overestimate
energy needs [1820]. More recent data and recommendations suggest that critically ill patients may require up to
130% of HBEE [2023]. Frankenfield et al. [24] found septic
patients had higher metabolic needs than did trauma patients
(190% HBEE versus 150%). A study comparing sepsis with
sepsis syndrome and septic shock also identified increased
metabolic rates, although patients in septic shock had the
lowest rates [22]. Patient hospitalized with NF are often
septic, undergo multiple surgical procedures and require
mechanical ventilation [4,25,26]; all of these factors indicate
metabolic stress. The degree of hypermetabolism in our
patients was somewhat less than these studies of septic

patients, but may be due to the use of actual body weight to

estimate HBEE rather than adjusting weights for obesity.
We chose to compare REE to HBEE alone rather than to
equations which include stress factors as determining which
factors (e.g. fever, sepsis, surgery, activity) to use was
difficult, and the use of more than one factor may quickly
lead to estimates >200% HBEE (e.g. HBEE  1.2 for bed
rest  1.6 for sepsis  1.2 for surgery = 230%) [16,17]. The
relevance of activity in this population is particularly
problematic as the most severely ill may be comatose,
chemically paralyzed and in bed with little activity. In one of
the most widely cited papers, Long et al. [15] report that
activity following surgery results in a minimal increase in
caloric expenditure; others suggest no additional energy
expenditure for resting, sleeping or reclining the
common activity of sick, ventilated patients [27]. As our
patients were generally sedated or sleeping, increased
energy needs can be attributed to stress rather than activity.
Majeski and Alexander [28], in one of the few studies to
address nutritional support in NF, reported giving twice
estimated basal calories either orally or via TPN. Sudarskys
group provided >3000 kcal/d [8]. These studies were
completed prior to the widespread advent of IC. Based on
IC measurements, our patients had slightly elevated energy
needs which peaked about 12 weeks post-admit, but
measured needs were far below targets previously reported.
Overall, energy requirements were elevated in this group
of patients. However, it is important to note the wide range of
caloric needs, including two patients (both >200% ideal
body weight) with REEs below predicted basal calories.
Several studies have commented on the large variations in
individual REE results. Large inter-individual differences
(as evidenced by S.D. and range) have been noted before
[19,20,23,24]. Both Vermeij et al. [23] and Saffle et al. [19]
have identified day-to-day variations for individual patients.
While the mean increase in metabolic rate was 124% above
HBEE, our patients also demonstrated both inter- and intraindividual differences as shown in Table 2 and Figs. 1 and 2.
Formulaic calorie recommendations do not suggest the
intra-individual differences noted here and by others
[18,19]. In spite of the variability in individual measurements, we found little difference in REE when comparing
initial IC to the overall average (Table 2). Two studies
[23,24] compared REE over time (07 days) in critically illseptic or trauma patients and found no significant change in
mean REE. Kreyman et al. [22] did note a change in
metabolic needs in patients with septic shock, with REE
increasing as shock resolved.
Repeated surgical procedures decrease the likelihood that
patients will meet their nutritional needs orally either
because of NPO status before and after surgery or from
decreased appetite due to pain, narcotics and other medical
conditions. Most patients in this study required multiple
surgeries that contributed to the need for nutritional support.
Mechanical ventilation also precludes adequate oral intake in
critically ill patients and may increase energy needs [29].

C. Graves et al. / Burns 31 (2005) 5559

Provision of nutritional support via TEN/TPN does not

assure adequate nutrient intake in a critically ill population.
In spite of early initiation of nutrition support (usually within
48 h) along with close monitoring of intake, most patients in
this group received less than target caloric intake, at least
during the period of monitoring. This appears likely related
to interruptions in nutrition prior to and during multiple
surgeries. More than half of the patients transferred to a subacute medical care or rehabilitation facility continued to
require nutritional support at the time of transfer.
Our data suggest that attempts to estimate nutrient
requirements based on any formula will inevitably lead to
over- or under-feeding and the risks associated with each.
Indirect calorimetry remains the most precise method
available to determine energy requirements. When IC is not
available, the data from this study suggest that providing
calories at 25 kcal/kg actual wt/d or about 124% of
estimated basal needs should meet most patients needs
and is consistent with published recommendations of
25 kcal/kg usual body weight/day [30].
While the data in this retrospective study is limited due
to lack of strict quality control measures and timing of
measurements in relation to clinical status, it confirms the
impression that patients with NF likely enter a hypermetabolic phase likely due to infectious and surgical stress.
5. Conclusion
Overall, the results presented suggests that those with NF
present with a wide range of medical, surgical and nutritional needs and with significant nutritional concerns and
need for aggressive nutritional intervention. The often
lengthy and complicated hospital course exacerbates these
nutrition concerns. While the data suggest provision of
calories at about 125% of HBEE (based on actual body wt)
or 25 kcal/kg/d may be adequate for most patients but that
providing adequate intake is often difficult due to complicated medical conditions and multiple surgical interventions. Clinicians need to recognize the large individual
variation possible and tailor nutrition support as needed
using IC whenever possible.
References
[1] Green R, Dafoe D, Raffin T. Necrotizing fasciitis. Chest
1996;110:21929.
[2] Maibach H. In: Dermatology, Moschella S, Hurly J, editors. Bacterial
Infections. Philadelphia: WB Saunders; 1992. p. 7301.
[3] Urschel J. Necrotiizing soft tissue infections. Postgrad Med J
1999;75:6459.
[4] Chapnick E, Abter E. Necrotizing soft-tissue infections. Infect Dis
Clin North Am 1996;10:83555.
[5] Quirk W, Sternbach G. Joseph Jones: Infection with flesh eating
bacteria. J Emerg Med 1996;14:74753.
[6] McHenry C, Piotrowski J, Petrinic D, Pizzi WF, Malangoni MA.
Determinants of mortality for necrotizing soft-tissue infections. Ann
Surg 1995;221:55863.

59

[7] Francis K, Lamaute H, Davis J, Pizzi WF. Implications of risk factors

in necrotizing fasciitis. Am Surg 1993;59:3048.
[8] Sudarsky L, Laschinger J, Coppa G, Spencer FC. improved results
from a standardized approach in treating patients with necrotizing
fasciitis. Ann Surg 1987;206:6615.
[9] Harris J, Benedict F. A Biometric Study of the Basal Metabolism in
Man, vol. publication no. 279. Washington, DC: Carnegie Institution
of Washington, 1919.
[10] Sellars B, Woods M, Morris S, Saffle J. Necrotizing group A streptococcal infections associated with streptococcal toxic shock syndrome.
Am J Surg 1996;172:5238.
[11] Burge J. Nutrition support of the obese patient. In: Matarese L,
Gottschlich M, editors. In Contempory Nutrition Support Practice: A
Clinical Guide. Philadelphia: WB Saunders; 1998. p. 5316.
[12] Choban P, Burge J, Flancbaum L. Nutrition support of obese hospitalized patients. Nutr Clin Pract 1997;12:14954.
[13] Cunningham J. Factors contributing to increased energy expenditure in
thermal injury: a review of studies employing indirect calorimetry.
JPEN 1990;14:64956.
[14] Fish J, Friedmann J. Metabolic stress. In: Matarese L, Gottschlich M,
editors. In Contemporary Nutrition Support Practice: A Clinical
Guide. Philadelphia: WB Saunders; 1998.
[15] Long C, Schaffel N, Geiger J, Schiller WR. Metabolic response to
injury and illness: estimation of energy and protein needs from indirect
calorimetry and nitrogen balance. JPEN 1979;3:4526.
[16] Mann S, Westenskow D, Houtchens B. Measured and predicted
caloric expenditure in the acutely ill. Crit Care Med 1985;13:
1737.
[17] Tsann-Long H, Huang S, Chen M. The use of indirect calorimetry in
critically ill patients the relationship of measured energy expenditure
to injury severity score, septic severity score, and APACHE II score. J
Trauma 1993;34:24751.
[18] McClave S, Snider H. Use of indirect calorimetry. Nutr Clin Pract
1992;7:20721.
[19] Saffle J, Medina E, Raymond J, Westenskow D. Use of indirect
calorimetry in the nutritional management of burned patients. J
Trauma 1985;25:329.
[20] Swinamer D, Grace M, Hamilton S, Jones RL. Predictive equation for
assessing energy expenditure in mechanically ventilated critically ill
patients. Crit Care Med 1990;18:65761.
[21] Boulanger B, Nayman R, McLean R, Phillips E. What are the critical
determinants of early energy expenditure in critically injured adults? J
Trauma 1994;37:96974.
[22] Kreyman G, Grosser S, Buggisch P, Gottschall C. Oxygen consumption and resting metabolic rate in sepsis, sepsis syndrome, and septic
shock. Crit Care Med 1993;21:10129.
[23] Vermeij C, Feenstra B, Van Lanschot J, Bruining HA. Day-to-day
variability of energy expenditure in critically ill surgical patients. Crit
Care Med 1989;17:6236.
[24] Frankenfield D, Wiles III C, Bagley S, Siegel JH. Relationships
between resting and total energy expenditure in injured and septic
patients. Crit Care Med 1994;22:1796994.
[25] File T, Tan S. Group A streptococcus necrotizing fasciitis. Comp Ther
2000;26:7381.
[26] Rouse T. Necrotizing fasciitis: a preventable disaster. Surgery
1982;92:7659.
[27] Pellet P. Food energy requirements in humans. Am J Clin Nutr
1990;51:71122.
[28] Majesky J, Alexander J. Early diagnosis, nutritional support,and
immediate extensive debridement improve survival in necrotizing
fasciitis. Am J Surg 1983;145:7847.
[29] Ireton-Jones C, Borman K, Turner W. Nutrition considerations in the
management of ventilator-dependent patients. Nutr Clin Pract
1993;8:604.
[30] Cerra F, Benitez M, Blackburn G, Jeejeebhoy K, et al. Applied
nutrition in ICU patients: a consensus statement of the American
College of Chest Physicians. Chest 1997;111:76978.