NUTRITION IN BURNS

Dr. Subodh kumar Asst. Prof Department of Plastic Surgery Osmania Medical College

Evolution of Burn Care:

Phase of surface applicants Phase of intravenous fluids and fluid therapy Phase of Antibiotics and wound infection Phase of early wound coverage- Tangential excision and

Skin grafting

Phase of nutritional support and Therapeutic nutrition

Metabolic changes:

Burn is associated with a Hypermetabolic state, seen in its most severe form. BMR is raised Increased protein loss due to exudation and protein breakdown, which may be as high as 40 gms N/ day which is 10 fold higher to any known condition The metabolic changes are dependant upon the TBSA, Infection, etc

 Hormonal changes:

Immunological Response:

Serum level of Catecholamines, Cortisol & Glucagon are raised Human Growth Hormone is elevated Insulin is lowered with decreased cell response Glucose tolerance is lowered resulting in Diabetic type picture

The malnutrition results in impaired immune response and immunological deficiency. The immunological compromise is dependant upon the age of the patient, TBSA, time after the injury, presence of infection, nutritional status etc. Such condition persists as long as the wounds are around.

Gastro- Intestinal Changes:

Pulmonary Changes:
Severe and early loss of respiratory muscle mass Compromise of ventilatory function Increased risk of respiratory infections Increased risk of pulmonary complications

Reduced mucosal barrier effect Ischemia- Reperfusion injury Reduced intestinal motility Mucosal edema Over growth of intestinal flora

Result:
Curlings ulcers & G.I.Bleed Translocation of the intestinal flora Endotoxemia and septicemia

Pulmonary failure is responsible

for nearly 45 % of burn deaths even in the absence

of respiratory burns.

Changes at cellular level:

There is shift of Sodium (Na) into the cells with Potassium (K) shifting out of the cell.

Sick Cell Syndrome

Energy Source: Glucose is the primary source of energy. But in the absence of adequate dietary supply of glucose, fatty acids and protein are used as alternate source of energy by proteolysis and lipolysis releasing Alanine, Glutamine and fatty acids which are used for Gluconeogenesis.

What are the clinical effects of these changes?

Severe loss of weight and malnutrition 20% of the body protein being lost in the first 2 weeks Loss of subcutaneous fat and muscle mass Tachycardia and high stroke volume and increased cardiac output Raised BMR and consequently elevation of basal temperature Fall in plasma proteins with reversal in A:G ratio Delayed wound healing Increased risk of infection High mortality

Loss of >10 % body mass leads to

decreased resistance and delayed wound healing.

Loss of more than >30 %

makes life improbable and mortality very high.

Management: Aim The aim of management of burn patient is to - resuscitate the patient from the injury, - achieve wound healing at the earliest, maintaining Positive metabolism all the while.

Nutritional support:

Early and aggressive nutritional support is necessary to counter the negative metabolic response seen in burns.

Nutritional support can be given either through enteral route or by parenteral route.

Enteral feeding

Nutrition in burns Parenteral Feeding

Necessary in the early stages as adequate quantities can not be give through oral route Pt. compliance is not required Immediate benefit Can be give for prolonged periods Safe even for the unconscious pts or those on ventilatory support A range of readymade products are available to choose from Infection Expensive Loss of weight

Maintains tropism of the GI tract Promotes release of hormones and growth factors Diet can be balanced and individualised Eliminates catheter contamination Prevents GI complications like ulceration and bleeding Encourages early return to normalcy Reduces proliferation and translocation of bacteria Cost effective Psychological advantage Intolerance or prolonged ileus

Benefits of Early feeds

Maintains tropism of the GI tract Reduces proliferation and translocation of bacteria Prevents GI complications like ulceration and bleeding

Early feeds & GI Bleed OGH Study

75 PATIENTS BETWEEN 10 & 70% TBSA BURNS WERE STUDIED FOR CLINICAL & ENDOSCOPIC EVIDENCE OF BLEED BY DIVIDING INTO 3 GROUPS GROUP I : RANITIDINE WAS ADMINISTERED FROM THE TIME OF ADMISSION.ENTERAL FEEDS WERE COMMENCEDAFTER 24 HOURS. GROUP II: SUCRALFATE AND EARLY FEEDS ARE ADMINISTERED FROM THE TIME OF ADMISSION. GROUP III: EARLY FEEDS WERE GIVEN FROM THE TIME OF ADMISSION,WITHOUT GIVING EITHER RANITIDINE OR ANTACIDS. PATIENTS WITH FACIAL/RESPIRATORY BURNS, PAST H/O APD, OR SIGNIFICANT MEDICAL ILLNESSES WERE NOT CONSIDERED. FIRST UGIE DONE AFTER STABILIZATION, REVIEW UGIE DONE AT WEEKLY INTERVALS

OBSERVATIONS - GI-LESIONS IN GROUPS

60
70 60 50 40 30 20 10 0 NORMAL UGIE LESIONS ON UGIE

60.71

48.4

39.29 40

51.6

Group I Group II Group III

OBSERVATIONS GI BLEED Cl.Vs UGIE-GROUPS

16 14 12 10 8 6 4 2 0

UGIE BLEED CLINICAL BLEED

R O

-CLINICAL BLEED WAS 5.33%(4/75), -THE BLEED ON UGI ENDOSCOPY WAS 9.59%(7/73). -NO BLEED EITHER ON UGIE OR CLINICALLY WAS SEEN IN THE GROUP GIVEN SUCRALFATE.

II

U P

U P

R O

R O

U P

III

Nutritional Support:

Start the feeds with in 6 hrs following injury Small frequent feeds are better tolerated than large single feed Total requirement is to be calculated using the standard formula 45 % - 50 % of the energy in the form of carbohydrates 30 % - 35 % of the energy in the form of fats 20 % of the energy in the form of protein Nitrogen: Non-nitrogen energy must be 1:150 Supplementation of Argenine, Glutamine and Omega 3 fatty acids is essential to enhance immune response Supplement Vitamin A, D, C, and Minerals like Ca, Zn and Mg on daily basis

Energy Requirement: Energy requirements are dependant upon body mass, TBSA, age & sex, presence of infection etc. Troell & Sutherland: 40 - 60 kcal / Kg / day Artz:60-90 kcal/Kg/day + 2-3 gms of protein/day William Curreri:25 kcal/Kg/day + 40 kcal/% burn/day

Glutamine and Arginine

Glutamine turns essential in burn injury Improves muscle metabolism and prevents loss of muscle mass It is an energy source for the intestinal mucosa and improves integrity of the gut mucosa Improves clinical response and N2 retention Reduces risk of infections Necessary to supplement Glutamine through diet

Arginine is a non essential dietary component

It is a specific precursor of nitric oxide

Secretogogue for Insulin,

Glucagon, Prolactin, Catecholamines and Growth

hormone

It is considered as conditionally essential amino acid

Needs to be supplemented

Fatty Acids:

Modulates inflammatory response Helps reduce severity of infections Reduces hospitalization Helps reduce mortality

Controversy over the requirement - 15 % to 35 % of

the energy requirement as fatty acids

Monitoring:

Every patient needs periodic monitoring at regular intervals Measurements of arm circumference Skin fold thickness Weight Serum proteins (Albumin) Hematocrit

Alteration of the diet are made based on the progress

Dietary advise:

All pts with major burn injury to be put on nasogastric feeding tube Start feeding immediately Clear liquids (Buttermilk, Barley water)1 to 2 ozs at 2nd Hrly intervals for 24 hrs As improvement is seen feeds are made richer by adding milk, egg white etc and quantity to be increased to 3 to 4 ozs per feed Solid foods are started by 4th day and by 6th day pt is able to take normal diet Cereals and pulces constitute the main bulk of the carbohydrate and egg or soyabean as protein source Every patient needs 1 liter of milk daily as skimmed milk Fat supplementation in the form of butter, ghee or fish oil Supplement adequate doses of vitamins, minerals and calcium daily

Our Routine: 0 to 48 hrs-2 ozs 2nd hrly- Buttermilk, milk and water 48 to 72 hrs - Continue 2nd hrly feed + 250 ml of milk+ egg white+ banana+ sugar 3rd to 5th day- Continue the established feed + Fermented steamed food (idly) in two servings 6th day onwards- Continue established feed + Normal diet By the end of 1st week- High protein formula feed is supplemented to the above diet, increased to 1 liter in a day Calcium, vitamins, and minerals are supplemented as capsules Diet is divided into 2nd hrly portions with three main meals in a day

High protein supplement formula feed:

Quantity:
Milk Eggs (white) Butter Bananas Sugar Caschew/ Badam seeds Barley water

500 ml
300 ml 2 Nos 50 gms 2 Nos 50 to 100 gms 75 gms 200 ml

Kcal

1976.4
(P: 55.4, F: 95.5, Ca:199.4 gms)

Osmania Formula:
Quantity: 260 gms

Black gram 30 gms Bengal gram 30 gms Groundnut 60 gms Soyabean 60 gms Jaggery 60 gms Ghee 20 gms

Kcal: 1225.3
(P: 55.9, F: 57.5, Ca: 121.47 gms)

Conclusion:

Nutrition in a burn patient is one of the major factors influencing the outcome. Understanding the metabolic changes and planning a therapeutic nutrition achieves better results Diet has to be customised for each individual patient based on the requirement, tolerance and acceptance Balancing the diet is a dynamic process and needs regular monitoring Avoiding monotony by changing the diet is essential Dietician must be a primary member in the burn care team

Thank you