nutrition in burns

8/3/2019 Nutrition in Burns

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NUTRITION INBURNSDr. Subodh kumarAsst. ProfDepartment of Plastic SurgeryOsmania Medical College


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Evolution of Burn Care:

Phase ofsurface applicants

Phase of intravenous fluids and fluid therapy

Phase of Antibiotics and wound infection

Phase of early wound coverage- Tangential excision and

Skin grafting

Phase of nutritional support and Therapeutic nutrition


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Metabolic changes:

Burn is associated with a Hypermetabolic state, seen in its

most severe form. BMR is raised

Increased protein loss due to exudation and protein breakdown,which may be as high as 40 gms N/ day which is 10 fold higherto any known condition

The metabolic changes are dependant upon the TBSA,Infection, etc


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Hormonal changes: Immunological

Response:

Serum level of

Catecholamines, Cortisol &

Glucagon are raisedHuman Growth Hormone is

elevated

Insulin is lowered with

decreased cell response

Glucose tolerance is loweredresulting in Diabetic type

picture

The malnutrition results in impaired

immune response and

immunological deficiency.The immunological compromise is

dependant upon the age of the

patient, TBSA, time after the injury,

presence of infection, nutritional

status etc.Such condition persists as long as

the wounds are around.


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Gastro- Intestinal Changes:

Severe and early loss of

respiratory muscle mass

Compromise of ventilatory

function

Increased risk of respiratoryinfections

Increased risk of pulmonary

complications

Pulmonary failure is responsible

for nearly 45 % of burn

deaths even in the absence

of respiratory burns.

Reduced mucosal barrier

effect

Ischemia- Reperfusion injury

Reduced intestinal motility

Mucosal edema

Over growth of intestinal flora

Result:

Curlings ulcers & G.I.Bleed

Translocation of the intestinalflora

Endotoxemia and septicemia

Pulmonary Changes:


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Changes at cellular level:

There is shift of Sodium (Na) into the cells with

Potassium (K) shifting out of the cell.

Sick Cell Syndrome


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Energy Source: Glucose is the primary source of energy. But in the absence of adequate dietary supply of

glucose, fatty acids and protein are used as alternate source of energy by proteolysis and lipolysis

releasing Alanine, Glutamine and fatty acids which are used for Gluconeogenesis.


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What are the clinical effects of these

changes?

Severe loss of weight and malnutrition

20% of the body protein being lost in the first 2weeks

Loss of subcutaneous fat and muscle mass Tachycardia and high stroke volume and increased

cardiac output

Raised BMR and consequently elevation of basaltemperature

Fall in plasma proteins with reversal in A:G ratio Delayed wound healing

Increased risk of infection

High mortality


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Loss of >10 % body mass leads to

decreased resistance and delayed wound

healing.

Loss of more than >30 %makes life improbable and mortality very high.


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Management:Aim

The aim of management of burn patient is to

- resuscitate the patient from the injury,

- achieve wound healing at the earliest, maintainingPositive metabolism all the while.


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Nutritional support:

Early and aggressive nutritional support is necessary tocounter the negative metabolic response seen in burns.

Nutritional support can be given either through enteralroute or by parenteral route.


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Nutrition in burns

Enteral feeding

Maintains tropism of the GI tract

Promotes release of hormones andgrowth factors

Diet can be balanced andindividualised

Eliminates catheter contamination

Prevents GI complications likeulceration and bleeding

Encourages early return to normalcy

Reduces proliferation andtranslocation of bacteria

Cost effectivePsychological advantage

Intolerance or prolonged ileus

Parenteral Feeding

Necessary in the early stages asadequate quantities can not begive through oral route

Pt. compliance is not required

Immediate benefitCan be give for prolonged periods

Safe even for the unconscious ptsor those on ventilatory support

A range of readymade products areavailable to choose from

Infection

Expensive

Loss of weight


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Benefits of Early feeds

.

Maintains tropism of the GI

tract

Prevents GI complications like ulceration and bleeding

Reduces proliferation and translocation of

bacteria


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Early feeds & GI Bleed OGH Study

75 PATIENTS BETWEEN 10 & 70% TBSA BURNS WERE STUDIED

FOR CLINICAL & ENDOSCOPIC EVIDENCE OF BLEED BY

DIVIDING INTO 3 GROUPS

GROUP I : RANITIDINE WAS ADMINISTERED FROM THE TIME

OF ADMISSION.ENTERAL FEEDS WERECOMMENCEDAFTER 24 HOURS.

GROUP II: SUCRALFATE AND EARLY FEEDS ARE

ADMINISTERED FROM THE TIME OF ADMISSION.

GROUP III: EARLY FEEDS WERE GIVEN FROM THE TIME OF

ADMISSION,WITHOUT GIVING EITHER

RANITIDINE OR ANTACIDS.

PATIENTS WITH FACIAL/RESPIRATORY BURNS, PAST H/O APD,

OR SIGNIFICANT MEDICAL ILLNESSES WERE NOTCONSIDERED.FIRST UGIE DONE AFTER STABILIZATION, REVIEW UGIE

DONE AT WEEKLY INTERVALS


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OBSERVATIONS - GI-LESIONS IN

GROUPS

60.71

39

.29

48.4

51.

660

40

0

10

20

30

40

50

60

70

NORMALUGIE

LESIONS ONUGIE

Group I

Group II

Group III


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OBSERVATIONS GI BLEED Cl.Vs

UGIE-GROUPS

0

2

4

68

10

12

14

16

GROU

PI

GROUP

II

GROUP

III

UGIE BLEED

CLINICALBLEED

-CLINICALBLEED

WAS 5.33%(4/75),

-THE BLEED ON

UGI ENDOSCOPY

WAS 9.59%(7/73).-NO BLEED

EITHER ON UGIE

OR CLINICALLY

WAS SEEN IN THE

GROUP GIVENSUCRALFATE.


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Nutritional Support:

Start the feeds with in 6 hrs following injury

Small frequent feeds are better tolerated thanlarge single feed

Total requirement is to be calculated using thestandard formula

45 % - 50 % of the energy in the form of

carbohydrates 30 % - 35 % of the energy in the form of fats

20 % of the energy in the form of protein

Nitrogen: Non-nitrogen energy must be 1:150

Supplementation of Argenine, Glutamine and Omega3 fatty acids is essential to enhance immuneresponse

Supplement Vitamin A, D, C, and Minerals like Ca,Zn and Mg on daily basis


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Energy Requirement:

Energy requirements are dependant upon body mass,TBSA, age & sex, presence of infection etc.

Troell & Sutherland: 40 - 60 kcal / Kg / day

Artz:60-90 kcal/Kg/day + 2-3 gms of protein/day

William Curreri:25 kcal/Kg/day + 40 kcal/% burn/day


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Glutamine and Arginine Glutamine turns essential in burn injury Improves muscle metabolism and prevents

loss of muscle mass

It is an energy source for the intestinal

mucosa and improves integrity of the gutmucosa

Improves clinical response and N2

retention

Reduces risk of infections

Necessary to supplement Glutaminethrough diet

Arginine is a non essential

dietary component

It is a specific precursor of

nitric oxide

Secretogogue for Insulin,

Glucagon, Prolactin,

Catecholamines and Growth

hormone

It is considered as conditionally

essential amino acid

Needs to be supplemented


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Fatty Acids:

Modulates inflammatory response

Helps reduce severity of infections

Reduces hospitalization Helps reduce mortality

Controversy over the requirement - 15 % to 35 % ofthe energy requirement as fatty acids


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Monitoring:

Every patient needs periodic monitoring at regularintervals

Measurements of arm circumference

Skin fold thickness

Weight

Serum proteins (Albumin)

Hematocrit

Alteration of the diet are made based on theprogress


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Dietary advise:

All pts with major burn injury to be put on nasogastric

feeding tube Start feeding immediately

Clear liquids (Buttermilk, Barley water)-

1 to 2 ozs at 2nd Hrly intervals for 24 hrs

As improvement is seen feeds are made richer by adding

milk, egg white etc and quantity to be increased to 3 to4 ozs per feed

Solid foods are started by 4th day and by 6th day pt isable to take normal diet

Cereals and pulces constitute the main bulk of thecarbohydrate and egg or soyabean as protein source

Every patient needs 1 liter of milk daily as skimmed milk Fat supplementation in the form of butter, ghee or fish

oil

Supplement adequate doses of vitamins, minerals andcalcium daily


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Our Routine:

0 to 48 hrs-2 ozs 2nd hrly- Buttermilk, milkand water

48 to 72 hrs - Continue 2nd hrly feed + 250ml of milk+ egg white+ banana+ sugar

3rd to 5th day- Continue the established feed+ Fermented steamed food (idly) in twoservings

6th day onwards- Continue established feed +Normal diet

By the end of 1st week- High protein formula

feed is supplemented to the above diet,increased to 1 liter in a day

Calcium, vitamins, and minerals aresupplemented as capsules

Diet is divided into 2nd hrly portions with three

main meals in a day


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High protein supplement formula feed:

Quantity: 500 ml

Milk 300 ml

Eggs (white) 2 Nos

Butter 50 gms

Bananas 2 Nos

Sugar 50 to 100 gms

Caschew/ Badam seeds 75 gms

Barley water 200 ml

Kcal 1976.4(P: 55.4, F: 95.5, Ca:199.4 gms)


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Osmania Formula:

Quantity: 260 gms

Black gram 30 gms

Bengal gram 30 gms

Groundnut 60 gms

Soyabean 60 gmsJaggery 60 gms

Ghee 20 gms

Kcal: 1225.3(P: 55.9, F: 57.5, Ca: 121.47 gms)


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Conclusion:

Nutrition in a burn patient is one of the major factorsinfluencing the outcome.

Understanding the metabolic changes and planning atherapeutic nutrition achieves better results

Diet has to be customised for each individual patientbased on the requirement, tolerance and acceptance

Balancing the diet is a dynamic process and needs regularmonitoring

Avoiding monotony by changing the diet is essentialDietician must be a primary member in the burn careteam


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Thank you

nutrition in burns

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