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Burns (1)

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أستاذنا الدكتور سمير الأنصاري

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Burns (1)

  1. 1. NUTRITION OF THE BURNED PATIENT Prepared by Rania Hassan Abdel Hafiez
  2. 2. Effects of Burn on the Body  Extensive inflammatory response  Rapid fluid shifts and accumulation.  Hypermetabolic state  Muscle protein catabolism  Decrease cardiac output because of increased capillary permeability and vasodilation.  Heat loss  Increased blood glucose levels  Burn Shock
  3. 3. Nutrition Therapy Goals Promote wound healing Maintain lean body mass Restore fluid levels
  4. 4. Hypermetabolism  Catecholamines, cortisol, and other glucocorticoids are increased in burn victims due to the stress state of the body causing a hypermetabolic response.  Epinephrine and norepinephrine increase 10-fold in people with burns greaterthat 30-40%.  Hypermetabolic state lasts 9-12 months aftera burn.
  5. 5. Glucose Metabolism  Accelerated gluconeogenesis, glucose oxidation and plasma clearance of glucose  Blood glucose levels increase due to insulin resistance and breakdown of glycogen stores  Glucagon excretion by the liverincreases initially afterthe burn and slows down as wound heals
  6. 6. Muscle Protein Catabolism Protein catabolismincreases in burn patients leading to protein losses of 260 mg protein/kg/hr. Catabolic hormones counteract the effect of insulin; as a result, blood sugarlevels rise, and protein synthesis and lipogenesis are inhibited. Growthhormoneis similarly antagonized and less effective.  Inthis environment, skeletal muscleis the majorobligatoryfuel. (compareto
  7. 7. Role of Specific Nutrients:  Kilocalories  Supplied by carbohydrate, protein, fat  Needed foroptimal tissue repair  Required forsynthesis of new cells  Sufficient calories is a priority so that protein will be spared
  8. 8. Determining Kcal Needs  Calculation of energy needs forthe burn patient remains challenging  % TBSA  Degree of burn  Othertrauma involved
  9. 9. Determining Kcal Needs  Predictive formulas  At least 30 formulas have been proposed  Harris-Benedict Equation: adds activity factorand stress factor  Ireton-Jones Equation: accounts forage, weight, gender, presence of trauma orburn, and ventilatory status  Kcalories/kg  Used forless severe burns (<20% TBSA)
  10. 10. 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 forvariability in energy expenditure fromchanges in metabolic state
  11. 11. Determining Kcal Needs  Indirect Calorimetry, continued Requirements fora valid measurement: Hemodynamically stable patient A cooperative orsedated patient Period of rest before measurement FiO2 < 60% Absence of chest tubes orother sources of airleak
  12. 12. Table 1: Nutrition Support forBurn Injuries Stressors Stress Factors Activity factor Confined to bed 1.2 Out of bed 1.3 Injury factor Minor operation 1.2 Skeletal trauma 1.3 Major surgery 1.4 Sepsis 1.6 Burn factor Stress Factor s 20% TBSA 1.2 20–25% TBSA 1.6 25–30%TBSA 1.7 30–35% TBSA 1.8 35–40% TBSA 1.9 40% TBSA 2.0 Table 1 Use of the modified Harris-Benedict equations to estimate resting energy expenditure Men: BEE=(66.47+13.75W+5. 0H-6.76A)x(Activity Factor)x(Injury and/or Burn Factor) Women: BEE=(655.1+19.56W+1. 85H-4.68A)x(Activity Factor) x(Injury and/orBurn Factor) W=weight in kg; H=height in cm;
  13. 13. Monitoring Nutritional Status  Body Weight  Weight should be measured regularly  Goal of weight maintenance is within 90%- 110% of pre-burn weight  Prealbumin  Short half-life of 2-3 days  Reflects recent nutrition intake  Depressed during acute phase response to burn
  14. 14. Monitoring Nutritional Status  Nitrogen Balance  Evaluates the adequacy of protein intake  Needs a 24 hoururine collection and a 24 hr UUN lab test  Nitrogen balance = nitrogen intake - nitrogen losses
  15. 15. Monitoring Nutritional Status  Nitrogen Balance, continued  Nitrogen intake = protein intake/6.25  Nitrogen losses =  Urinary nitrogen losses (24 hrUUN)  Otherlosses 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
  16. 16. Monitoring Nutritional Status  Indirect Calorimetry (Metabolic Cart)  Periodic measurements aid in evaluating adequacy of caloric intake  Measures resting energy expenditure (REE)  A factorof 10% to 30% added forcalorie needs during PT and wound care
  17. 17. Protein Requirements  Amino acids are important forcollagen synthesis forwound healing  Maintaining visceral protein is important for organ function especially forimmune systems  Maintaining intercostal muscles and the diaphragmis imperative forrespiratory efficiency  1.4-2.2 g/kg protein requirement forburns  Urinary nitrogen losses increase with severity of the burn injury  Trauma patient may lose 20-25 g of lean body
  18. 18. Protein Requirement cont…  Protein requirement estimate:  Combine 24-hoururinary nitrogen loss, 2 to 4 g of nitrogen forfecal loss and 4 to 5 g/d for anabolism.  Convert each gram of nitrogen to 6.25 g of protein.  Patients are likely to miss feedings if in surgery frequently so should be given high protein formulas between surgeries  Be aware of uremia- increase free water  Generally 20-25% of calories from protein
  19. 19. Lipid requirements  Lipid stores are critical forlong-termfuel after majorthermal burns  Fat oxidation is higherin hypermetabolic patients than in normal patients  Fat consumption should not exceed 30% of the diet to avoid diarrhea  Beneficial because  Fat is a more concentrated formof energy  Vegetable oils contain essential fatty acids and fat soluble vitamins  Help with infection
  20. 20. Carbohydrate Requirements  Carbohydrate metabolismis significantly affected in burn patients  Gluconeogenesis fromAlanine and otherAAs are elevated  Carbohydrates are good sources forprotein sparing especially fornitrogen retention  High carbohydrates can contribute to hyperglycemia in which case a diet can be altered to increase fat in the diet  Recommended 60% of the calories fromCHO, not surpassing 400g/d or1600 kcal/d
  21. 21. Vitamin C  Needed foredema prevention  Involved in collagen synthesis forwound healing  Aid in immune functioning
  22. 22. Vitamin A  Needed forimmune function  Epithelialization  5000 IU of Vitamin A per1000 cal of enteral feeding is recommended
  23. 23. Vitamin Dand Calcium  Burns cause an impairment in the metabolism of Vitamin D  Burn patients are more susceptible to fractures so calciumand vitamin Dshould be administered  Calcium- 1000 mg daily  Vitamin D- 200-400 IU daily  Maintain serum25-hydroxy vitamin Dlevel of 30-60 ng/Ml
  24. 24. Zinc and Copper  Zinc and copper deficiencies have been seen in burn patients most likely fromtissue breakdown and urinary excretion.  Supplementation is recommended for patients
  25. 25. Conditionally essential amino acids Glutamine
  26. 26. Methods of Nutrient Delivery  Oral Intake  Burns <25% TBSA in olderchildren and adults and <15% TBSA in young children and infants  High-calorie, high-protein supplements  Modularcalorie and protein enhancement of oral foodstuffs
  27. 27. Methods of Nutrient Delivery  Enteral Nutrition (EN)  Most burn patients can tolerate a standard formula  Formula with high nitrogen content  Transpyloric feedings are bettertolerated  EN is preferred to parenteral nutrition (PN)
  28. 28. Methods of Nutrient Delivery  Parenteral Nutrition (PN, TPN, PPN)  Associated with complications  Intestinal dysmotility  Hepatic steatosis  Septic morbidity  Catheter-related infection  ASPEN guidelines: limit use of PN to patients in whomEN is contraindicated orunlikely to meet nutritional needs in 4-5 days
  29. 29. Conclusions  An aggressive nutrition approach forthe burn patient is indicated to:  address hypermetabolism  enhance nitrogen retention  support wound healing  improve survival
  30. 30. Adequate nutrition Successful wound healing
  31. 31. Hehas too muchfoodto eat 
  32. 32. Thank you

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