Unit 7: Burns and Surgery

1. Unit 7: Burns and Surgery

2. Burn • A severe burn is perhaps one of the most painful injuries a human being can receive. • The amount of trauma suffered by patients with burns is dependent upon the type of burn, extent of the burn injury, and their age. *The likelihood of mortality from second and third degree burns increases with age.

3. Aggressive nutrition therapy for burn patients • *Factors that affect successful feeding of burn patients include: -- Difficult swallowing or chewing -- Psychological trauma -- Anorexia -- A loss of more than 10% of preburn body weight places the patient at high risk for sepsis and/or death.

4. Aggressive nutrition therapy for burn patients (continued) --* “Fast” foods, favorite dishes from home, and any other desired items should be encouraged. -- *The burn patient is thirsty and dehydrated despite the edema that may be present. Replacement of fluid and electrolyte losses is important for patients to recovery from burns. Sodium and potassium are the two electrolytes most likely to be deficient.

5. Aggressive nutrition therapy for burn patients (continued) • Most clinicians prescribe 2 to 10 times the RDAs for water-soluble vitamins for burn patients. *Vitamin C is given in amounts 20 to 30 times the RDA. • *Foods high in zinc increase wound healing. These include: • Meat • Liver • Eggs • Seafood.

6. Calculating nutrient needs for burn patients • A burn patient has a special need for calories and protein in large amounts to replace fat loss, repair and deposit lean tissues, maintain body functions, and restore water loss. The calorie requirement may be as large as 6000-8000 kcal/day. • *Daily caloric need = 25 kcal/kg of normal body weight + 40 kcal/ % of body surface burned.

7. Calculation • Given: A patient weighs 75 kg and has 50% of body surface burned. • Calculate his daily caloric need.

8. Answer • 25 kcal/kg body weight x 75 kg body weight + 40 kcal% body surface with burns x 50% body surface with burns = (25x75+40x50) kcal = 3875 kcal Allow 1000 kcal for margin of safety: Approximately 4500 to 5000 kcal

9. Calculating nutrient needs for burn patients (continued) - A burn victim needs more protein to cover skin loss, blood protein loss from the burn and infection. • *Total daily protein need = 1 g/kg normal body weight + 3 g % body surface with burns.

10. Calculation • Given: Adult weighs 75 kg and that 50% of the body surface has burns. • Calculate the total protein need.

11. Answer • Total daily protein need = 1 g/kg body weight x 75 kg body weight + 3 g/% body surface with burns x 50 % body surface with burns = 225 g protein

12. Nutrition prior to surgery • *Good nutrition prior to surgery can: -- Shorten recovery time -- Increase resistance to infection -- Decrease the mortality rate * Most patients are not at optimum nutritional status before they go to surgery.

13. NPO before surgery • *Usually nothing is given by mouth for at least 8 hours prior to surgery to avoid food aspiration during anesthesia.

14. Postoperative nutrition • Since a patient usually cannot tolerate solid food immediately after an operation, it is withheld anywhere from a few hours to 2 or 3 days. A feeding that is too early may nauseate the patient and cause vomiting and possible aspiration.

15. Postoperative nutrition (continued) • Although solid foods are withheld from patients immediately after an operation, most hospitals provide patients with oral feedings after their intestinal functions return to normal (as early as 24 hours after the operation). *The feedings consist of routine hospital progressive diet. Nutritional supports, including fluids, electrolytes, protein, calories, and other nutrients, should be carefully reviewed by dietitians/nutritionists and physicians.

16. Postoperative nutrition (continued) • Depending on the patient and his/her condition, a combination of feeding methods, including tube feeding, may be used. • *Tube feedings can be commercially-made or home-made. From the standpoint of accuracy in measuring, sanitation, and convenience, most hospitals prefer commercial tube feeding mixtures.

17. Postoperative nutrition (continued) • The goal of postoperative diet therapy is to replace body losses as soon as possible. Energy, protein, and ascorbic acid (vitamin C) are major factors in achieving rapid wound healing. • *Vitamin C is essential to wound healing, since it provides a cementing substance to build strong connective tissue. • Some food sources of vitamin C: Citrus fruits, sweet and hot peppers, greens, strawberries, broccoli, tomatoes, cantaloupe, cabbage, etc.

18. *Multiple choice • Q: Which of the following foods is the highest in ascorbic acid? • Cole slaw • Egg whites • Peanut butter • Creamed cottage cheese

19. Answer • (a) Cole slaw

20. Postoperative nutrition (continued) • *The postoperative diet must be high in calories, protein, vitamins, minerals, and fluids. • The undernourished patient, because of a lack of the major nutrients necessary for recovery, it is at higher risk in surgery than a patient of normal weight. *Protein deficiency is most common among these patients. Low protein storage will predispose the patient to shock, less detoxification of the anesthetic agent by the liver, increased edema at the infection site, and decreased antibody formation.

21. Postoperative nutrition (continued) • *Complete dietary protein of high biological value is essential to tissue building and wound healing after surgery because it supplies all the essential amino acids needed for tissue synthesis. • *Up to 1 pound of muscle tissue protein per day may be lost following surgery through bleeding, high metabolic rate (using protein for energy), catabolism of muscle tissue, and from surgery itself.

22. Postoperative nutrition (continued) • If the caloric intake in the postoperative patient is inadequate, protein will be used for energy rather than for tissue rebuilding and wound healing. More than half of ingested proteins will be used to provide energy in the absence of sufficient carbohydrates and fats. *A minimum of 2800 calories per day from carbohydrates and fat must be available to spare protein for its primary purpose.

23. *Multiple choice • Situation: If a patient is 2-day postoperative following a hysterectomy and tells you she wants to be on a 1000 calorie reduction diet when she is allowed to eat again. What would be our most appropriate response to her? • Ask her doctor to prescribe 1000 calorie diet. • Explain that tissue repair requires more nutrients than 1000 calorie diet. • Tell her a 1000 calorie high protein diet will be OK. • Explain that a reduction diet should be at least 1200 calories.

24. Answer • (b) Explain that tissue repair requires more nutrients than 1000 calorie diet.

25. *Stress related to surgery • All kinds of stress related to surgery may: • 1. Reduce the function of the GI tract. • 2. Interfere with the desire to eat. • 3. Deplete liver glycogen: After an overnight fast, liver glycogen is rapidly depleted due to decreased plasma insulin and a rise in glucagon levels. Carbohydrate stores are exhausted. Liver glycogen is used first, followed by muscle glycogen.

26. Wound healing functions of some vitamins • Vitamin C: cementing material for connective tissue. • Folic acid: formation of hemoglobin. • Vitamin K: Essential for blood clotting. • Thiamin (vitamin B1): Coenzyme in carbohydrate metabolism.

27. Reference • Stanfield, P., & Hui, Y. (2003). Nutrition and Diet Therapy (Fourth Edition). Sudbury: Jones and Bartlett Publishers.