Transcript Slide 1

Nutritional Needs
of the Burn Patient
Joan LeBoeuf, RD, CNSD
UNM Burn Center
Adult & Pediatric Injury
from tragedy… hope!
Topics of Discussion
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Kcal Needs
Protein Needs
Micronutrient Supplementation
Methods of Nutrient Delivery
Nutritional Monitoring
UNM Burn Center: from tragedy… hope!
Nutrition
… A Crucial Component of Care
• Hypermetabolism
– Burns=Highest kcal needs than that of any other injury
or disease
– Proportional to the extent of the burn injury
• Hypercatabolism
– Burns=Highest protein needs
– Erosion of lean body mass
• Adequate nutrition = Successful wound healing
Role of Specific Nutrients:
Kilocalories
• Kcals
– Supplied by carbohydrate, protein, fat
– Needed for optimal tissue repair
– Required for synthesis of new cells
– Sufficient calories is a priority so that protein
will be spared
Determining Kcal Needs
• Calculation of energy needs for the burn
patient remains challenging
– % TBSA
– Degree of burn
– Other trauma involved
Determining Kcal Needs
• Predictive formulas
– At least 30 formulas have been proposed
• Harris-Benedict Equation: adds activity factor and stress factor
• Ireton-Jones Equation: accounts for age, weight, gender,
presence of trauma or burn, and ventilatory status
• Kcalories/kg
– Used for less severe burns (<20% TBSA)
Determining Kcal Needs
• Indirect Calorimetry (Metabolic Cart)
– Considered to be the “gold standard”
– An indirect method of calculating energy expenditure
and respiratory quotient using measurements of
inspired and expired gas
– Most closely related to actual energy expenditure
– Accounts for variability in energy expenditure from
changes in metabolic state
Determining Kcal Needs
– Indirect Calorimetry, continued
• Requirements for a valid measurement:
– Hemodynamically stable patient
– A cooperative or sedated patient
– Period of rest before measurement
– FiO2 < 60%
– Absence of chest tubes or other sources of air
leak
Role of Specific Nutrients:
Protein
– Needed for cell multiplication, collagen and connective
tissue formation and increased enzyme activity
– The nutrient most compromised by burn injury
– Extensive nitrogen losses, relative to wound size, are
noted in wound exudate and urine
– Protein needs
• 20-25% of kcals
• 1.5 to 3.0 g/kg
Role of Specific Nutrients:
Micronutrients
• Severely burned patients (>20% TBSA) may
require micronutrient supplementation due to
metabolic changes and increased losses from
wounds.
– vitamin A, vitamin C, Zinc, multivitamin
• <20% TBSA, a multivitamin alone may be
sufficient to meet needs
Micronutrient Guidelines After
Thermal Injury
• Adults and Children (>3y, >40 lbs, >20% TBSA)
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1 multivitamin q day
500 mg ascorbic acid bid
10,000 IU vitamin A q day**
220 mg zinc sulfate q day
• **For tube-fed patients, vitamin A supplementation should be
discontinued once the feeding formula is administered at a rate
that would meet vitamin A requirements.
Micronutrient Guidelines After
Thermal Injury
• Children (<3y, <40 lbs, >10% TBSA)
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1 children’s multivitamin q day
250 mg ascorbic acid bid
5000 IU vitamin A q day**
110 mg zinc sulfate q day
• **For tube-fed patients, vitamin A supplementation should be
discontinued once the feeding formula is administered at a rate
that would meet vitamin A requirements.
Methods of Nutrient Delivery
• Oral Intake
– Burns <25% TBSA in older children and adults
and <15% TBSA in young children and infants
– High-calorie, high-protein supplements
– Modular calorie and protein enhancement of
oral foodstuffs
Methods of Nutrient Delivery
• Enteral Nutrition (EN)
– Most burn patients can tolerate a standard
formula
– Formula with high nitrogen content
– Transpyloric feedings are better tolerated
– EN is preferred to parenteral nutrition (PN)
Methods of Nutrient Delivery
• Parenteral Nutrition (PN, TPN, PPN)
– Associated with complications
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Intestinal dysmotility
Hepatic steatosis
Septic morbidity
Catheter-related infection
– ASPEN guidelines: limit use of PN to patients in whom
EN is contraindicated or unlikely to meet nutritional
needs in 4-5 days
Monitoring Nutritional Status
• Body Weight
– Weight should be measured regularly
– Goal of weight maintenance is within 90%-110% of preburn weight
• Prealbumin
– Short half-life of 2-3 days
– Reflects recent nutrition intake
– Depressed during acute phase response to burn
Monitoring Nutritional Status
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Nitrogen Balance
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Evaluates the adequacy of protein intake
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Needs a 24 hour urine collection and a 24 hr UUN lab
test
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Nitrogen balance = nitrogen intake - nitrogen losses
Monitoring Nutritional Status
• Nitrogen Balance, continued
– Nitrogen intake = protein intake/6.25
– Nitrogen losses =
• Urinary nitrogen losses (24 hr UUN)
• Other losses from non-urea urinary nitrogen, fecal,
sweat, etc. (3-5 g)
• Burn wound nitrogen losses
– <10% open wound = 0.02 g/kg
– 11% to 30% open wound = 0.05 g/kg
– >30% open wound = 0.12 g/kg
Monitoring Nutritional Status
• Indirect Calorimetry (Metabolic Cart)
– Periodic measurements aid in evaluating
adequacy of caloric intake
– Measures resting energy expenditure (REE)
• A factor of 10% to 30% added for calorie needs
during PT and wound care
Conclusions
• An aggressive nutrition approach for the
burn patient is indicated to:
– address hypermetabolism
– enhance nitrogen retention
– support wound healing
– improve survival
References
• ASPEN Board of Directors and the Clinical Guidelines Task Force.
Guidelines for the use of parenteral and enteral nutrition in adult and
pediatric patients. J Parenter Enteral Nutr. 2002;26(suppl):S88-S90.
• Mayes T, Gottschlich MM. Burns and wound healing. In: Gottschlich
M, Fuhrman MP, Hammond KA, Holcombe BJ, Seidner, DL, eds. The
Science and Practice of Nutrition Support: A Case-based Core
Curriculum. Dubuque, Ia: Kendall/Hunt Publishing Co; 2001:391-420.
• Lefton J. Specialized Nutrition Support for Adult Burn Patients.
Support Line. 2003;25(4);19-25.
• Trujillo E, Robinson M, Jacobs J. Critical Illness. In: The ASPEN
Nutrition Support Practice Manual. Silver Spring, MD: ASPEN;
1998:18-1-18-14.
Questions…
one child burned, is one child too many!
Joan LeBoeuf, RD, CNSD
UNM Burn Center
Adults & Pediatrics
from tragedy… hope!