Nutrition - Post-burn nutrition support

Increased awareness of metabolic and nutritional needs has significantly improved recovery
and survival rates in burns patients, writes Sandra Brady

Nutrition is an important component of treatment of patients with large burns.

Severely burned patients develop a number of physiological alterations including a markedly

elevated metabolic rate, which persist over an extended period of time.

Other metabolic changes include:

An increased rate of glucose production and utilisation

An increased rate of lipolysis and increased protein catabolism and anabolism
An increased energy expenditure in severe burns which exceeds that of any other
injury.

These factors must be considered when deciding on appropriate nutritional management of

the burned patient.

The goals of nutrition support are to defend lean body mass, promote immunocompetence,
optimise wound healing and reduce subsequent duration of recovery.

Assessment

Nutritional requirements must be assessed individually for each patient. The patient should
be weighed on admission, as weight gain from fluid is common during the resuscitation
period.

If a dry weight is unavailable, pre-burn weight should be used. Many formulae exist for
predicting energy expenditure. Factors including the size of the burn wound, activity,
temperature, sex and age of the patient should be considered when estimating the patients
requirements. Indirect calorimetry permits actual measurement of energy expenditure
where metabolic carts are available.

Both overfeeding and underfeeding can have negative consequences in critically ill patients.
Underfeeding impairs immunocompetence and wound healing and has a negative effect on
mortality.

Overfeeding may cause complications such as hyperglycaemia, hepatic steatosis and elevated
CO2 production. It is therefore essential to reassess energy requirements regularly and
modify nutritional support accordingly.

Protein

Protein requirements are significantly increased in burned patients. Protein is necessary for
wound healing, enhancement of host defence mechanisms and replacement of losses.
Extensive nitrogen losses occur from the burn wound exudate and in the urine. The degree of
protein catabolism is related to the size of the burn.

Protein requirements remain elevated until the burn wound is closed. Higher protein intakes
have been associated with improved mortality in patients with major burns. Specific amINO
acids may also improve outcome.

Micronutrients

Micronutrient requirements must also be considered post-burn as protein and energy cannot
be effectively utilised if micronutrient intakes are inadequate.

Trace elements such as zinc and copper are lost in exudate from the burn wound and
selenium may be lost during surgical procedures such as excision and grafting. Urinary losses
of trace elements also increase. Early trace element supplementation appears beneficial after
major burns.

Certain vitamin requirements are also increased, for example:

Vitamin C is necessary for collagen synthesis and immune function

Vitamin A is required for epithelialisation and maintenance of the immune response
High energy intakes also lead to an increased demand for B vitamins.

Additional vitamins and minerals are therefore necessary to replace losses and meet
increased requirements for wound healing.

Methods of nutrition intervention

Nutritional requirements may be achieved by:

High protein, high calorie diet (including oral nutritional supplements)

High protein, high calorie diet with supplemental enteral feeding
Enteral feeding.

Adult patients with less than 15%-20% TBSA (total body surface area) burns may achieve
their nutritional requirements orally. Patients with larger burns and/or inhalation injuries
will generally require enteral feeding.

Early enteral feeding confers many benefits on the burned patient and is the preferred
method of feeding.

Total parenteral nutrition is rarely used and has been shown to significantly increase
mortality in severely burned patients.

Nasojejunal feeding should be considered in patients with significant burn injury where
nasogastric feeding has been unsuccessful.

Enteral feeding

Enteral feeding should be initiated as early as possible post-burn. Many burns units now feed
enterally within six hours of admission.

Early enteral feeding increases gut blood flow and decreases gut mucosal atrophy and
therefore may prevent bacterial translocation.
Early enteral nutrition has been shown to blunt the post-burn hypermetabolic response,
reduce weight loss, improve nitrogen balance, reduce hospital stay and decrease mortality in
patients successfully fed. It is also effective in the prevention of stress haemorrhage in the
upper gastrointestinal tract.

Delayed enteral feeding is associated with elevated catabolic hormones, gut mucosal atrophy,
increased metabolic rate and an increased risk of post-burn malnutrition.

Retrospective studies have shown that delays of more than 18 hours before initiation of
enteral feeding are unfavourable and significantly reduce the success rate.

High protein, high calorie diets with oral nutritional supplements should be encouraged
where possible. Oral intake should be monitored and nutritional intervention modified
accordingly.

Burns patients dietary intake may be compromised by a number of factors (see Table 2),
which must be considered when devising a treatment plan.

Multiple surgical procedures may be necessary, traditionally involving withholding

nutritional support during the perioperative period.

For this reason the safety and feasibility of providing enteral nutrition throughout operative
procedures has been investigated.

Intraoperative duodenal feeding with monitoring of tube position and gastric reflux were
demonstrated to be well tolerated and resulted in increased energy intake and decreased
wound infection.

Recovery period

Nutritional requirements decrease and approach pre-injury levels as wound healing

progresses. Research indicates that increased protein intake during the recovery phase
increases body weight gain and muscle function.

Patients on discharge may require a high protein, high calorie diet until wound healing is
complete and weight loss has been corrected.

Patients requiring nutritional assessment and intervention

Adults with 15% or greater total body surface area (TBSA) burns (10% in children)
Patients with inhalation injury
Those with poor nutritional status on admission 
Those on therapeutic diets
Patients whose dietary intake is inadequate post-admission
Those whose intake is compromised by facial or hand burns

Factors affecting dietary intake

Nausea or vomiting
Anorexia
Pain
Constipation/diarrhoea
 Procedures, eg. change of dressing
Frequent surgical intervention

Much progress has been made in the treatment of burns patients. This includes early excision
and grafting, improved management of burns shock, inhalation injury and infection.

These factors together with an increased awareness of metabolic and nutritional needs and
advances in nutrition support have significantly improved survival in burns patients.

Sandra Brady is a clinical nutritionist specialist at St James's Hospital, Dublin

(References on request)

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