A 65-year-old male was admitted to the ICU with 40% TBSA burns. He has a history of smoking and alcohol use. On exam, he has burns on his face, arms, back, buttocks, and legs requiring escharotomy. His calorie needs are estimated at 4,752 kcal/day and protein at 162 g/day. The nutrition care plan is to start NPO with EN at 60 ml/hr increasing to 120 ml/hr over 36 hours to provide 4,300 kcal, 497 g CHO, 146 g fat, 270 g protein and prevent sepsis. Labs will be monitored for stabilization.

1. Nutrition Support
for Burn Injury
Andreina Martin,
Stephanie Ontiveros,
Claudia Rodriguez,
Stephanie Villalobos,
Nelson Zeledon

2. Patient Introduction
JA is a 65 y/o male, admitted as a level 2 trauma with 40% TBSA to the Surgical
ICU for a burn injury.
● Chief Complaint:
○ Two different stories.
○ Patient says body caught on fire and he put it out by jumping on the floor
or into a ravine.

3. Social History
○ JA is a smoker, 1 pack per day for more than 30 years
○ Alcohol- 2-3 beers daily and a case on Saturdays and
Sundays
○ Years of education: 11.
○ Unemployed and lives alone

4. Physical Exam
● The patient’s current general appearance shows that he is
intubated and has been put under.
● Soot found in the nares and oropharynx, located in the nose,
and dry mucous membranes in the throat.
● Vitals:
○ Temp: 100
○ HR: 120 (tachycardia)
○ Respiratory rate: 22
○ BP: 140/93
○ SpO2: 98%.
● Burns: Entire face. Partial thickness burns on bilateral upper
extremities, lower back and buttocks. Full thickness to lower
extremities. 1st
degree burns near umbilicus. Blistering over
scrotum and head of the penis.
● Due to the patient’s bilateral lower extremities burns, an
escharotomy procedure is to be conducted.

6. Class of Burns

7. Zone Of Necrosis
Zone of Coagulative Necrosis
Zone of Stasis
Zone of Hyperaemia

8. Burn Patient Considerations
Shock
Sepsis
Respiratory Insufficiency
Shift of Body fluids into interstitial compartments
Loss of Protein in Plasma causing edema
Excess loss of heat > Hypermetabolic State > Increased Kcal Needs
At risk for Opportunistic infection/growth of microorganism > Pseudomonas
Aeruginosa, MRSA, Candida infections > Sepsis

9. Common Investigations
Hemoglobin
Blood gases
Chest xray
Haematocrit
Electrolyte balance
Blood glucose
ECG
Creatine Kinase
Urinary myoglobin
Bun

10. Medications Nutrient/Drug Interactions
● Docusate- Monitor fluid status, electrolyte balance and fiber intake
● Silver sulfadiazine - topical antibiotic.
● Acetaminophen -Limit alcohol, caffeine and Vitamin C
● Midazolam - Caution with grapefruit, herbal sedatives and stimulants
● Hydromorphone- Fluid status must be
monitored
● Propofol-Need to consider kcal intake
● 1.1 Kcal per mL
● Famotidine

11. Anthropometric Data
○ Patient J.A., male, 65 y/o.
○ Height: 6 feet (72”).
○ Weight (actual) 71.2kg (156.64#).
○ Weight (usual): 71.2 kg (156.64#).
○ Weight (ideal): 80.9kg (178#).
○ 88% IBW. 100%UBW.
○ BMI: 21.24 (normal - stable weight for past 6 mo.)

12. Diet History
○ Diabetic
○ No Specific diet
○ Has not monitored blood glucose for ~1 year.
○ NPO with EN upon admission.
■ (ASPEN: begin EN 4-6 hours upon onset of injury).

13. Final Nutrition Care Plan
ESTIMATED CALORIE NEEDS
Zawacki Equation
1440 Kcal/d × BSA
Patient BSA: 1.82m²
1440 kcal/d x 1.82m² =
4,752 kcal/day
ESTIMATED PROTEIN NEEDS
1.5-2.0g/kg for burn patients
Patient IBW: 178#, 81kg
2.0g x 81kg =
162 g/day

14. Final Nutrition Care Plan
Nutrition diagnosis:
● Recommend NPO with EN Pivot 1.5 @60
ml/hr with final goal rate of 120 ml/hr to
provide: 4300 kcal, 497g CHO, 146g Fat, 270g
Protein, 2.2L free water.
● Total kcals adjusted due to propofol
providing about 280 kcals from Fat

15. Final Nutrition Care Plan
PES
1. Inadequate energy intake R/T patient in hypermetabolic state AEB Predicted energy
of 4750 kcal
2. Inadequate enteral nutrition infusion R/T current diet order AEB Current infusion rate
only meets 40% of estimated needs
3. Altered nutrition related lab values R/T altered kidney function and catabolic
response to burn injury AEB hyperkalemia, low total protein, hypercalcemia,
hyperglycemia and hypomagnesemia

16. Final Nutrition Care Plan
● Nutrition Intervention
○ Assure pt is meeting daily energy requirements (Total: 4700 kcal)
○ Assure pt is meeting daily protein requirements (Total: 280g)
○ Reach proper infusion rate of 120 ml/hr within 36 hrs to prevent sepsis.
○ Prevent progression of kidney damage by discussing possible drug-nutrient interactions with MD.
● Monitoring and Evaluation
○ Monitor Pts. daily EN intake to assure he’s receiving 4,300 Kcal, 497 g CHO, 146g fat, 270g protein,
and 2.2 L water, and make adjustments as his condition progresses.
i. Monitor gastric residuals to determine tolerance
○ With adjustment of EN the following labs will stabilize as follows
i. Pt. blood K+ levels will lower to a normal range of 3.5-5.0 mEq/L,
ii. Pt. blood Ca+ levels will lower to a normal range of 8.8-10.4 g/dL
iii. Pt. Total protein will increase to normal range of 6.0-8.3 g/dL

17. Multiple Choice Questions
1. Which of the following is NOT a type of burn
a. Electrical
b. Chemical
c. Thermal
d. Sepsis

18. Multiple Choice Questions
1. Which of the following is NOT a type of burn
a. Electrical
b. Chemical
c. Thermal
d. Sepsis

19. Multiple Choice Questions
2. According to ASPEN guidelines, Enteral nutrition should be
administered to burn patients within:
a. 4-6 hours of injury onset.
b. 24 hours of injury onset
c. 48 hours of injury onset
d. 72 hours of injury onset

20. Multiple Choice Questions
2. According to ASPEN guidelines, Enteral nutrition should be
administered to burn patients within:
a. 4-6 hours of injury onset.
b. 24 hours of injury onset
c. 48 hours of injury onset
d. 72 hours of injury onset