Nutritional Needs of the Burn Patient

1. Nutritional Needs of the Burn Patient Joan LeBoeuf, RD, CNSD UNM Burn Center Adult & Pediatric Injury from tragedy… hope!

2. Topics of Discussion • Kcal Needs • Protein Needs • Micronutrient Supplementation • Methods of Nutrient Delivery • Nutritional Monitoring UNM Burn Center: from tragedy… hope!

3. Nutrition… A Crucial Component of Care • Hypermetabolism • Burns=Highest kcal needs than that of any other injury or disease • Proportional to the extent of the burn injury • Hypercatabolism • Burns=Highest protein needs • Erosion of lean body mass • Adequate nutrition = Successful wound healing

4. Role of Specific Nutrients: Kilocalories • Kcals • Supplied by carbohydrate, protein, fat • Needed for optimal tissue repair • Required for synthesis of new cells • Sufficient calories is a priority so that protein will be spared

5. Determining Kcal Needs • Calculation of energy needs for the burn patient remains challenging • % TBSA • Degree of burn • Other trauma involved

6. Determining Kcal Needs • Predictive formulas • At least 30 formulas have been proposed • Harris-Benedict Equation: adds activity factor and stress factor • Ireton-Jones Equation: accounts for age, weight, gender, presence of trauma or burn, and ventilatory status • Kcalories/kg • Used for less severe burns (<20% TBSA)

7. 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 for variability in energy expenditure from changes in metabolic state

8. Determining Kcal Needs • Indirect Calorimetry, continued • Requirements for a valid measurement: • Hemodynamically stable patient • A cooperative or sedated patient • Period of rest before measurement • FiO2 < 60% • Absence of chest tubes or other sources of air leak

9. Role of Specific Nutrients:Protein • Needed for cell multiplication, collagen and connective tissue formation and increased enzyme activity • The nutrient most compromised by burn injury • Extensive nitrogen losses, relative to wound size, are noted in wound exudate and urine • Protein needs • 20-25% of kcals • 1.5 to 3.0 g/kg

10. Role of Specific Nutrients:Micronutrients • Severely burned patients (>20% TBSA) may require micronutrient supplementation due to metabolic changes and increased losses from wounds. • vitamin A, vitamin C, Zinc, multivitamin • <20% TBSA, a multivitamin alone may be sufficient to meet needs

11. Micronutrient Guidelines After Thermal Injury • Adults and Children (>3y, >40 lbs, >20% TBSA) • 1 multivitamin q day • 500 mg ascorbic acid bid • 10,000 IU vitamin A q day** • 220 mg zinc sulfate q day • **For tube-fed patients, vitamin A supplementation should be discontinued once the feeding formula is administered at a rate that would meet vitamin A requirements.

12. Micronutrient Guidelines After Thermal Injury • Children (<3y, <40 lbs, >10% TBSA) • 1 children’s multivitamin q day • 250 mg ascorbic acid bid • 5000 IU vitamin A q day** • 110 mg zinc sulfate q day • **For tube-fed patients, vitamin A supplementation should be discontinued once the feeding formula is administered at a rate that would meet vitamin A requirements.

13. Methods of Nutrient Delivery • Oral Intake • Burns <25% TBSA in older children and adults and <15% TBSA in young children and infants • High-calorie, high-protein supplements • Modular calorie and protein enhancement of oral foodstuffs

14. Methods of Nutrient Delivery • Enteral Nutrition (EN) • Most burn patients can tolerate a standard formula • Formula with high nitrogen content • Transpyloric feedings are better tolerated • EN is preferred to parenteral nutrition (PN)

15. 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 whom EN is contraindicated or unlikely to meet nutritional needs in 4-5 days

16. 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

17. Monitoring Nutritional Status • Nitrogen Balance • Evaluates the adequacy of protein intake • Needs a 24 hour urine collection and a 24 hr UUN lab test • Nitrogen balance = nitrogen intake - nitrogen losses

18. Monitoring Nutritional Status • Nitrogen Balance, continued • Nitrogen intake = protein intake/6.25 • Nitrogen losses = • Urinary nitrogen losses (24 hr UUN) • Other losses 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

19. Monitoring Nutritional Status • Indirect Calorimetry (Metabolic Cart) • Periodic measurements aid in evaluating adequacy of caloric intake • Measures resting energy expenditure (REE) • A factor of 10% to 30% added for calorie needs during PT and wound care

20. Conclusions • An aggressive nutrition approach for the burn patient is indicated to: • address hypermetabolism • enhance nitrogen retention • support wound healing • improve survival

21. References • ASPEN Board of Directors and the Clinical Guidelines Task Force. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr. 2002;26(suppl):S88-S90. • Mayes T, Gottschlich MM. Burns and wound healing. In: Gottschlich M, Fuhrman MP, Hammond KA, Holcombe BJ, Seidner, DL, eds. The Science and Practice of Nutrition Support: A Case-based Core Curriculum. Dubuque, Ia: Kendall/Hunt Publishing Co; 2001:391-420. • Lefton J. Specialized Nutrition Support for Adult Burn Patients. Support Line. 2003;25(4);19-25. • Trujillo E, Robinson M, Jacobs J. Critical Illness. In: The ASPENNutrition Support Practice Manual. Silver Spring, MD: ASPEN; 1998:18-1-18-14.

22. Questions… one child burned, is one child too many! Joan LeBoeuf, RD, CNSD UNM Burn Center Adults & Pediatrics from tragedy… hope!