nutritional needs of the burn patient joan leboeuf, rd, cnsd unm burn center adult & pediatric...
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Nutritional Needs of the Burn Patient
Joan LeBoeuf, RD, CNSD
UNM Burn Center
Adult & Pediatric Injury
from tragedy… hope!
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Topics of Discussion
• Kcal Needs
• Protein Needs
• Micronutrient Supplementation
• Methods of Nutrient Delivery
• Nutritional Monitoring
UNM Burn Center: from tragedy… hope!
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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
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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
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Determining Kcal Needs• Calculation of energy needs for the burn
patient remains challenging– % TBSA– Degree of burn– Other trauma involved
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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)
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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
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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
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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
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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
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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.
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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.
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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
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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)
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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
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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
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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
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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
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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
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Conclusions
• An aggressive nutrition approach for the burn patient is indicated to:– address hypermetabolism– enhance nitrogen retention– support wound healing– improve survival
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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 ASPEN Nutrition Support Practice Manual. Silver Spring, MD: ASPEN; 1998:18-1-18-14.
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Questions…
one child burned, is one child too many!
Joan LeBoeuf, RD, CNSD
UNM Burn CenterAdults & Pediatricsfrom tragedy… hope!