Nutrition in Burns: Role of Early Feeding

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Nutrition in
Burns
Role of Early Feeding
Robertus Arian Datusanantyo (EAN)
Plastic Surgeon
RSUD Prof. Dr. W. Z. Johannes – Kupang

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Why is it extremely important
to manage nutrition carefully
in burns?
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(Carson et. al., 2018)
Classic Ebb and Flow Phase Ebb and Flow Phase in Burn Injury

Metabolic “Double Hit”
Increased demand for
anabolic metabolism
for wound healing.
Triggering a systemic
catabolic state.
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Mismatch
Functional Malnutrition

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(Clark et. al., 2017;Carson et. al., 2018)
Resting Energy Expenditure Metabolic Shift Toward Proteolysis

“ … the burn patients are
internally warm and not
externally cold.”

“Thus, the burn patient’s metabolism is taxed with
the challenge of generating sufficient heat to
maintain a higher body temperature with less
heat-conserving resources.”

(Wilmore et. al., 1974)
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(Clark et. al., 2017)

Hypermetabolism
•  Cathecolamine: primary mediator of
hypermetabolism
•  Inhibition of protein synthesis and lipogenesis
•  Catabolic state: significant weight loss
–  10% weight loss: Immune dysfunction
–  20% weight loss: Impaired wound healing
–  30% weight loss: Severe infection
–  40% weight loss: Mortality
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Early Enteral Feeding
•  Improved muscle mass maintenance,
•  Modulation of stress hormone levels,
•  Improved gut mucosal integrity,
•  Improved wound healing,
•  Decreased risk of Curling ulcer formation,
•  Shorter intensive care unit stay
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Carbohydrate
•  50 – 60% calories needs,
limit:
–  5 gram/kg/day – Adult
–  7 gram/kg/day – Children
•  Excess: increasing
hyperglycemia with
resultant lactic acidosis
•  Titrate to limit and
substitute with protein
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Fats
•  Intact fat stores: small needs in
diet
•  To minimize hepatic steatosis, the
percentage of dietary calories
from fat should be limited and
carefully monitored.
•  Fat: 3 – 15% from total calories
need
•  TPN: 0.5–1 g/kg (one to two times
per week)
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Protein
•  Proteolysis: metabolic hallmark of
the hypermetabolic response
•  Requirements:
–  1.5–2 g/kg per day: adults
–  2.5–4 g/kg per day: children
•  Excess:
–  Urea load
–  Azotemia
•  Alanine, arginine, and glutamine:
burn wound healing
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“Even at these high
rates of replacement,
most burn patients will
experience some loss of
muscle protein due to
the hormonal and
proinflammatory
response to burn
injury.”

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Glutamine in Burns
•  Glutamine provides fuel for lymphocytes and
enterocytes
•  Essential for maintaining small bowel
integrity
•  Preserving gut-associated immune function
•  Cellular protection after stress, as it increases
the production of heat shock proteins
•  Precursor of glutathione: a critical
antioxidant
•  Glutamine of 25 g/kg/day of glutamine:
reduce mortality and length of stay
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Monitoring & Evaluation
•  No single method available
•  Underfeeding:
–  Delayed wound healing, immonocompromise state,
pulmonary alteration
•  Overfeeding:
–  Hypercapnea, metabolic acidosis,
hypertrigliseridemia, hyperglicemia, azotemia,
hepatic dysfunction
•  Body weight, nitrogen balance, lean body mass imaging,
serum protein level
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Conclusions
•  Hypermetabolism state in burns
advocates careful nutrition
support management.
•  Early feeding is recommended.
•  Carbohydrate, fat, protein, trace
elements based on calory needs è
individualized.
•  Glutamine supplementation plays
significant role in burns.
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Further Readings
Alexander, J. W. et al. (1980) ‘Beneficial Effects of Aggressive Protein Feeding in Severely Burned Children’, Annals
of Surgery, 192(4), pp. 505–517.
Carson, J. S. et al. (2018) ‘Nutritional Needs and Support for the Burned Patient’, in Herndon, D. N. (ed.) Total
Burn Care. 5th edn. Edinburgh: Elsevier, pp. 287–300.
Clark, A. et al. (2017) ‘Nutrition and metabolism in burn patients’, Burns and Trauma, 5(1), pp. 1–12
Heyland, D. et al. (2013) ‘A Randomized Trial of Glutamine and Antioxidants in Critically Ill Patients’, New
England Journal of Medicine, 368(16), pp. 1489–1497.
Kozar, R. A. et al. (2004) ‘The immune-enhancing enteral agents arginine and glutamine differentially modulate
gut barrier function following mesenteric ischemia/reperfusion’, Journal of Trauma - Injury, Infection and
Critical Care, 57(6), pp. 1150–1156.
Lam, N. N., Tien, N. G. and Khoa, C. M. (2008) ‘Early enteral feeding for burned patients-An effective method
which should be encouraged in developing countries’, Burns, 34(2), pp. 192–196.
Pu, H. et al. (2018) ‘Early enteral nutrition reduces mortality and improves other key outcomes in patients with
major burn injury: A meta-analysis of randomized controlled trials’, Critical Care Medicine, 46(12), pp. 2036–
2042.
Wasiak, J., Cleland, H. and Jeffery, R. (2006) ‘Early versus delayed enteral nutrition support for burn injuries’,
Cochrane Database of Systematic Reviews, (3).
Wilmore, D. W. et al. (1974) ‘Catecholamines: Mediator of the Hypermetabolic Response to Thermal Injury’,
Annals of Surgery, 180(4), pp. 653–669..

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Nutrition in Burns: Role of Early Feeding

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