Published on January 4, 2008
Nutritional Care of Burn Patients: Nutritional Care of Burn Patients Kari Osmondson Concordia College Objectives: Objectives Identify the types and degree of burns Understand the bodies metabolic, hormonal, and immune response to burns Identify proper energy requirements for burn victims Understand the significance of carbohydrate, protein, and fat in burn patients Recognize the vitamins and minerals important in burn healing Definition of a Burn: Definition of a Burn “Tissue injury caused by thermal, radiation, chemical, or electrical contact resulting in protein denaturation, burn wound edema, and loss of intravascular fluid volume due to increased vascular permeability.” The Merck Manual of Diagnosis and Therapy Seventeenth Edition (1999) Four Types of Burns: Four Types of Burns Thermal Radiation Chemical Electrical Types of Burns: Types of Burns Thermal Caused by external heat source which raises the temperature of skin and deeper tissue to a level that causes cell death and protein coagulation Examples: Flame, hot objects or gases touching skin, scalding liquids Radiation Caused by prolonged or intense exposure to ultraviolet radiation Examples: Sunburn, tanning beds Types of Burns: Types of Burns Chemical Caused by strong acids, alkalis, phenols, cresols, phosphorus or mustard gas Results in necrosis Electrical Caused by electric current which may generate heat up to 5000ºC May result in necrosis, respiratory paralysis, or ventricular fibrillation Burn Injury: Burn Injury Severity depends on: Depth of burn Extent of surface area involved Layers of the skin Epidermis Protect inner tissue from microorganisms & prevent water loss Basal layer- bottommost layer, can regenerate Dermis Provides strength and durability Contains sweat glands, hair follicles, nerve endings, blood vessels First-Degree Burns: First-Degree Burns Does not go below basal layer of the epidermis Dry and painful Appears red due to increased blood flow Heals in a few days Second-Degree Burns: Second-Degree Burns Extends below basal layer, but not completely through dermis Superficial Blister, very painful, contains skin parts (adnexa) which assist in epithelialization Deep Partial-thickness Deeper in dermis, fewer adnexa, longer healing time, less painful Third-Degree Burns: Third-Degree Burns Extends completely through dermis Adnexa destroyed so can’t heal by epithelialization Dermal plexus of nerves destroyed-less painful Burns can be yellow, red, black, brown Fourth-Degree Burns: Fourth-Degree Burns Extend beneath fat into bone and/or muscle Electrical burns Metabolic Response: Metabolic Response Hypermetabolism Up to 100% basal energy required by a healthy person Severe weight loss Weight loss >10% shown to increase mortality Weight loss >30% associated with almost 100% mortality Negative nitrogen balance Basal Metabolic Rate decreases during recovery period Normal in 10-14 days Hormonal Response: Hormonal Response Increased circulating catecholamines, cortisol, and glucagon Normal or slightly elevated insulin levels More circulating glucagon than insulin Amino acids and glycerol utilized for gluconeogenesis Increased proteolysis and lipolysis Release of large amounts of amino acids, glycerol, and free fatty acids Immune Response: Immune Response Adversely affected by bodies systemic response Impaired with protein-energy malnutrition and nutrient deficiency Rule of Nines: Rule of Nines Estimation of total burn area Percentage of total body area Head & Neck = 9% Arm = 9% each Trunk = 18% each side Genitalia & Perineum = 1% Leg = 18% each Adult Energy Requirements: Adult Energy Requirements Curreri formula Daily energy requirement = (25W + 40B) Long formula BEE x activity factor x injury factor Male BEE = 66.6 + 13.8W + 5H – 6.8A Female BEE = 655 + 9.6W + 1.9H – 4.7A Activity factors: 1.2 if confined to bed 1.3 if out of bed Injury factor: 2.1 for severe thermal burn W=weight in kg, B=total burn area as % of total body mass, H=height in cm, A=age in years Adult Energy Requirements: Adult Energy Requirements Ireton-Jones Formula Ventilator-dependent (EEVv) or breathing spontaneously (EEVsp) EEVv = 1925 – 10A + 5W + 218S + 292T + 851B EEVsp = 629 – 11A + 25W – 609O W=weight in kg; A=age in years; S is score for sex (male 1, female 0); T, B, and O are scores for trauma, burns, and obesity (each score 1 if present, 0 if absent) Child Energy Requirements: Child Energy Requirements Wolfe Formula Energy = BMR x 2 BMR Calculations Age Boys Girls 0-3 years 60.9W – 54 61W – 51 4-10 years 22.7W + 459 22.5W + 499 11-18 years 17.5W + 651 12.2W + 746 W= weight in kg Child Energy Requirements: Child Energy Requirements Modified Galveston formula < 1 year: (2100 x BSA) + (1000 x burn area) < 12 years: (1800 x BSA) + (1300 x burn area) 12-18 years: (1500 x BSA) + (1500 x burn area) BSA = body surface area in m2 Burn area = surface area burned in m2 Child Energy Requirements: Child Energy Requirements Curreri Junior Formula < 1 year RDA + 15B 1-3 years RDA + 25B 4-15 years RDA + 40B RDA in kcal 0-0.5 years 320 kcal 0.5-1 500 1-3 740 4-6 950 7-10 1130 11-14 1140 (male) 1310 (female) 15-18 1760 (male) 1370 (female) Carbohydrate Requirements: Carbohydrate Requirements Glucose reduces extent of hypermetabolic response and protein breakdown High rates of glucose delivery: Causes hyperglycaemia needing insulin Stimulates hepatic lipogenesis & altered liver function Increased CO2 production Prevents & slow weaning from ventilator Adults: 5 mg/kg/min avoids complications Children: 5-7 mg/kg/min Infants: D5W 5 mg/kg/min initially then increased to a max of 15 mg/kg/min over first few days CHO limited to 50% energy intake Fat Requirements: Fat Requirements Normal diet leads to muscle wasting with central obesity due to hepatic steatosis Fat reduction prevents problems when protein replaces lipid energy Adults: Minimum of 4% total energy 15% meets essential fatty acid requirements and provides for fat-soluble vitamins Vary composition of fats Children: Minimum of 2-3% total energy Infants: Maximum of 4g/kg of IBW Protein Requirements: Protein Requirements Intact protein rather than amino acids Improved weight maintenance and survival Frequent estimations of nitrogen loss to ensure adequate replacement TNL = TUN + 4g TNL = (UUN x 1.25) + 4g NB = TNL – NS 6.25 g protein = 1 g nitrogen Adults: 2-3 g protein/kg IBW Children: < 1 year old: 3-4 g protein/kg IBW 1-3 years old: 2.5-3 g protein/kg IBW >3 years old: 1.5-2.5 g protein/kg IBW 25% energy as protein Arginine: Arginine Associated with improved immune function 9% protein as arginine Reduced infection rate & hospital stay Precursor to nitric oxide Causes vasodilatation Increases blood flow to wound Enhances collagen deposition Glutamine: Glutamine Most abundant amino acid in body Preserves integrity of intestinal mucosa and permeability Stimulates blood flow to gut Maintains immune function and reduces infection Decreases bacterial translocation & survival Animal study, not yet found in humans Ornithine α-ketoglutarate: Ornithine α-ketoglutarate Precursors of glutamate and glutamine Ornithine helps synthesize arginine Supplementation 10-20 g/day Improve nitrogen balance Reduce protein catabolism Improve wound healing Improve glucose tolerance and nutritional status De Bandt, J., Coudray-Lucus, C., Lioret, N., Lim, S., Saizy, R., Giboudeau, J., &Cynober, L. (1998). A randomized controlled trial of the influence of the mode of enteral ornithine α-ketoglutarate administration in burn patients. Journal of Nutrition, 128: 563-568. Vitamin Requirements: Vitamin Requirements Specific requirements not established for most Multivitamin supplementation Vitamin A Immune function & epithelialization 10,000 IU/day < 3 years old: 5,000 IU/day Vitamin Requirements: Vitamin Requirements Vitamin C Immune function Wound Healing Collagen synthesis Free radical scavenging properties limits tissue damage Ascorbic acid study High doses reduced resuscitation fluid volume, body weight gain, wound edema, & severity of respiratory dysfunction Adults: 500 mg twice a day Children up to age 10: 250 mg twice a day Tanaka, H., Matsuda, T., Miyagantani, Y., Yukioka, T., Matsuda, H., & Shamazaki, S. (2000). Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration: a randomized, prospective study. Journal of the American Dietetic Association, 100: 1094. Mineral Requirements: Mineral Requirements Injury decreases copper, iron, selenium, & zinc levels Copper, zinc, selenium supplements Fewer complications Quicker return to normal plasma levels of micronutrients Improved leucocyte response Shorter hospitalization Watch calcium, phosphorus, magnesium, sodium, & potassium for imbalances Enteral vs. Parenteral Feeding: Enteral vs. Parenteral Feeding Enteral preferred over parenteral Maintains integrity of GI tract Parenteral more expensive & increases complications Hospital-made vs. commercial diets Hospital made diets as good as commercial Weight gain & protein increase similar Patient tolerance similar Our Role As Dietitians: Our Role As Dietitians Make proper energy recommendations Be sure patients receiving adequate amounts of carbohydrate, protein, and fat Be sure patients receiving proper vitamin and mineral supplementation Select proper feeding route Individualization Standards of Practice: Standards of Practice Use height, weight, and rule of nines to calculate proper energy and nutrient needs Use lab values of TUN and UUN to calculate the total nitrogen loss and/or balance Frequent estimations for adequate replacement Ethical Issues: Ethical Issues Overestimation of energy requirements Whole foods vs. enteral nutrition vs. parenteral nutrition References: References Beers, M., & Berkow, R. (Eds.). (1999). Burns. The Merck Manual of Diagnosis and Therapy, Whitehouse Station: Merck Research Laboratories. De Bandt, J., Coudray-Lucus, C., Lioret, N., Lim, S., Saizy, R., Giboudeau, J., &Cynober, L. (1998). A randomized controlled trial of the influence of the mode of enteral ornithine α-ketoglutarate administration in burn patients. Journal of Nutrition, 128: 563-568. De-Souza, D., & Green, L. (1998). Pharmacological nutrition after burn injury. Journal of Nutrition, 128, 797-801. Dhanraj, P., Chacko, A., Mammen, M., & Bharathi, R. (1997). Hospital-made diet versus commercial supplement in postburn nutritional support. Burns, 23, 512-514. Greenhalgh, D. (1996). The healing of burn wounds. Dermatology Nursing, 8 (10), 13-25. Mahan, L., & Escott-Stump, S. (Eds.). (2000). Krause’s Food, Nutrition, & Diet Therapy. 10th Edition. Philadelphia: WB Saunders Company. References: References Persinger, M. (1997). Burn protocol sets goals for protein and micronutrient intake. Journal of the American Dietetic Association, 5: 495. Rose, D. (1999). Perioperative management of burn patients. Association of Operating Room Nurses Journal, 69: 1208-1224. Sadler, M., Strain, J., & Caballero, B. (Eds.). (1999). Burns Patients. Encyclopedia of Human Nutrition (Vol. 1, pp 197-205). San Diego: Academic Press. Tanaka, H., Matsuda, T., Miyagantani, Y., Yukioka, T., Matsuda, H., & Shamazaki, S. (2000). Reduction of resuscitation fluid volumes in severely burned patients using ascorbic acid administration: a randomized, prospective study. Journal of the American Dietetic Association, 100: 1094.