Nutritional Management
of a Moderate to Severely
Burned Adult Patient.
Case Study by Morgan West
Preceptor: Ann Kvitek, MS, RD, CNSC, CDE, CD
Emergent Care
Wound management
Respiratory support
Fluid resuscitation
Cardiovascular stabilization
Pain control
Assessment of burn severity
Emergent Care
Wound management
Respiratory support
Fluid resuscitation
Cardiovascular stabilization
Pain control
Assessment of burn severity
Type
Depth
% TBSA
Classification to Minor, Moderate or Severe
Wound Management
Burn Wound Excision
In full thickness injury, all necrotic & infected tissue
must be removed
Viable wound bed of fascia, fat or muscle is left
Types of Excisions
Tangential excision
Full thickness excision
Fascial excision
Burn wound coverage/closure
Autograft
Allograft
Artificial Dermis, i.e. Integra
Types of Burns:
(1) Radiation
(2) Chemical
(3) Electrical
(4) Cold Temperature
(5) Thermal
Flame
Scald
Contact
Flash
http://accidentattorneys.org/wp-content/uploads/2015/01/31019823_m300x200.jpg
Burn Depth
Superficial
Partial Thickness
Superficial Partial
Thickness
Deep Partial Thickness
Full Thickness
Fourth Degree
Burn Depth
Superficial 1st
Partial Thickness
2nd
Superficial Partial
Thickness
Deep Partial Thickness
Full Thickness 3rd
Fourth Degree
Superficial
Skin layers affected:
epidermis
Physical signs: redness,
pain to touch, mild
swelling
Treatment: cool
compresses, tends to heal
in 2-3 days without special
attention
http://www.leememorial.org/HealthInformation/HIE
%20Multimedia/1/000030.htm
Partial Thickness
Skin layers affected:
epidermis & upper regions
of the dermis
Physical signs: deep
redness, increased pain,
swelling, blistering
Treatment: sterile, nonadhesive dressing, heals in
1-2 weeks
Full Thickness
Skin layers affected:
epidermis, dermis &
hypodermis
Physical signs: skin layer
loss, often painless, dry,
leathery skin, skin is charred,
gray white or cherry red
Treatment: Requires
immediate medical attention
Skin grafting usually
necessary.
% TBSA
Estimation methods:
(1) Rule of Nines
(2) Lund-Browder Formula
Rule of Nines
Each leg 18%
Each arm 9%
Trunk 36%
Head 9%
Perineum 1%
http://www.uwmedicine.org/airlift-nw/Documents/burn-pocket-card-final.pdf
Lund-Browder Formula
http://www.forensicmed.co.uk/wounds/burns/burn-area/
American Burn Associations
Grading System for Burn Severity
Type of
Burn
Criteria
Minor
< 10% TBSA in adults
< 5% TBSA in patients under 10 or above 50 years
of age
< 2% full-thickness burn
Moderate
10-20% TBSA burn in adults
5-10% TBSA in patients under 10 or above 50
years of age
2-5% full thickness burn
High voltage injury
Suspected inhalation injury
Circumferential burn
Concomitant medical problem predisposing patient
to infection
Severe
> 20% TBSA in adults
> 10% TBSA in patients under 10 or above 50
years of age
American Burn Associations
Grading System for Burn Severity
Type of
Burn
Criteria
Minor
< 10% TBSA in adults
< 5% TBSA in patients under 10 or above 50 years
of age
< 2% full-thickness burn
Moderate
10-20% TBSA burn in adults
5-10% TBSA in patients under 10 or above 50
years of age
2-5% full thickness burn
High voltage injury
Suspected inhalation injury
Circumferential burn
Concomitant medical problem predisposing patient
to infection
Severe
> 20% TBSA in adults
> 10% TBSA in patients under 10 or above 50
years of age
Medical Management
Wound management
Prevention of deep vein thrombosis
Burn wound infection
Patients with > 20% TBSA at increased risk for
infections
Nutritional management
Pain management
Medical Management
Wound management
Prevention of deep vein thrombosis
Burn wound infection
Patients with > 20% TBSA at increased risk for
infections
Nutritional management
Pain management
Nutritional Management
Metabolic Response
Ebb Phase & Flow Phase
Sustained Hypermetabolic Response
Energy/Protein Requirements
Nutrition Support
Oral Nutrition
Glutamine
Arginine
Oxandralone
Vitamin/Mineral Supplementation
Metabolic Response
Ebb Phase occurs within first 48 hours of injury
Decreased tissue perfusion
Increased capillary permeability with vasodilation
Increased peripheral vascular resistance
Increased blood viscosity
Massive fluid shifts from circulating plasma to interstitial fluid
Decreased oxygen consumption
Decreased cardiac output
Decreased metabolic rate
Impaired glucose tolerance & hyperglycemic state
Flow Phase
Increased tissue perfusion
Increased oxygen consumption
Increased cardiac output
Increased body temperature
Sustained hypermetabolic response
Metabolic Response
Ebb Phase occurs within first 48 hours of injury
Decreased tissue perfusion
Increased capillary permeability with vasodilation
Increased peripheral vascular resistance
Increased blood viscosity
Massive fluid shifts from circulating plasma to interstitial fluid
Decreased oxygen consumption
Decreased cardiac output
Decreased metabolic rate
Impaired glucose tolerance & hyperglycemic state
Flow Phase
Increased tissue perfusion
Increased oxygen consumption
Increased cardiac output
Increased body temperature
Sustained hypermetabolic response
Sustained Hypermetabolic
Response
A 10- to 20-fold elevation in catecholamines
and corticosteroid levels, which persists up to
12 months post injury and an increase in
inflammatory cytokines, which peaks
immediately after injury & approaches normal
levels 1-2 months post injury leads to:
Increased lipolysis, protein catabolism,
gluconeogenesis & REE
Energy Requirements
(1) Indirect Calorimetry
(2) Harris-Benedict equation x AF x IF of 1.6 2.0
Men: BEE = 66.5 + 13.8 (weight) + 5 (height) 6.76
(age)
Women: BEE = 655 + 9.6 (weight) + 1.85 (height) 4.68
(age)
(3) Curreri Formula
Age 16-59: 25 kcal/kg + 40 kcal/ %TBSA
Age >/= 60: 20 kcal/kg + 65 kcal/ %TBSA
(4) 35 kcal/kg; used in practice, no evidence to support
(5) Toronto
REE (kcal) = -4343 + (10.5 x TBSA burned) + (0.23 x
kcals) + (0.84 x Harris Benedict) + (114 x T ( oC)) - (4.5 x
days post-burn)
Energy Requirements
(1) Indirect Calorimetry
(2) Harris-Benedict equation x AF x IF of 1.6 2.0
Men: BEE = 66.5 + 13.8 (weight) + 5 (height) 6.76
(age)
Women: BEE = 655 + 9.6 (weight) + 1.85 (height) 4.68
(age)
(3) Curreri Formula
Age 16-59: 25 kcal/kg + 40 kcal/ %TBSA
Age >/= 60: 20 kcal/kg + 65 kcal/ %TBSA
(4) 35 kcal/kg; used in practice, no evidence to support
(5) Toronto
REE (kcal) = -4343 + (10.5 x TBSA burned) + (0.23 x
kcals) + (0.84 x Harris Benedict) + (114 x T ( oC)) - (4.5 x
days post-burn)
Thermal Injury factor:
2025% TBSA: 1.6
2530% TBSA: 1.7
3035% TBSA: 1.8
3540% TBSA: 1.9
4045% TBSA: 2.0
> 45% TBSA: 2.1
Protein Requirements
1.5 2.0 g/kg/day balances protein synthesis &
breakdown in setting of burn hypermetabolism.
Nutrition Support
Minor to moderate burn patients who we anticipate will be
able to meet needs orally within a few days can tolerate a
few days of inadequate nutrition & do not require formal
nutrition support.
Enteral Nutrition therapy should be initiated if:
Patient intubated and unable to eat orally for a multiple days
Severe burn injury (>20% TBSA) with needs that cannot
reasonably be met via oral intake
Timing & Route:
Initiated within hours of injury
Both gastric or post-pyloric feedings can be used successfully
Very early enteral feeding (within 6-12 h post injury) via
gastric route is associated with:
Attenuation of stress hormone levels & hypermetabolic response
Increased immunoglobulin production
Reduced risk of malnutrition. (ESPEN)
Oral Nutrition
High calorie/high protein meals
Nutritional supplements
Burn Shakes
No free water juices or Gatorade
Vitamin/Mineral
Supplementation:
< 20% TBSA
Multivitamin + minerals 1 tab 2x/day for 5 days, then decrease to 1x/day
Vitamin C, 500 mg 2x/day
20-40% TBSA
Multivitamin + minerals 1 tab 2x/day for 14 days, then decrease to
1x/day
Vitamin C, 500 mg 2x/day
> 40% TBSA
Multivitamin + minerals 1 tab 2x/day for 21 days, then decrease to
1x/day
Vitamin C, 500 mg 2x/day
Increased micronutrients requirements (i.e. trace elements and
vitamins) due to:
Hypermetabolic response
Increased requirements for wound healing
Increased loses via open wounds
Glutamine
Non-essential amino acid
Increased turnover rates; synthesis cannot keep up
with demands after severe burn injury.
Inconsistent data for supplementation post-burn
Use at UW; 20 g/day for 12 days for > 25% TBSA.
Oxandralone
Reduces weight loss and preserves lean body mass
Synthetic testosterone derivative with similar
androgenic & anabolic actions
Case Presentation
CE is a 34 year old male with no significant past
medical history.
Admitted with 58% TBSA burn secondary to flame
contact after petroleum tank explosion. Workrelated injury.
No inhalation injury, all burns third degree.
Previously well-nourished, with no specific dietary
needs or restrictions.
Surgical History
Day 1: 4 escharotomies BLE
Day 3: fascial excision & placement of Integra to BLE
Day 7: STSG right arm & trunk, allograft to bilateral buttocks
Day 14: STSG bilateral hands, allograft to anterior chest
Day 21: Allograft to chest, flank, abdomen, bilateral groin & buttocks
Day 28: Allograft to trunk & bilateral buttocks
Day 35: STSG back, allograft to anterior trunk, buttocks & bilateral legs
Day 42: STSG to anterior trunk & replacement of
Day 49: exchange of cadaver grafting on trunk & gluteal region
Day 56: STSG to buttocks & bilateral thighs, removal & replacement of cadaver
allograft to bilateral lower legs & anterior left thighs
Day 63: Non-selective debridement & replacement of cadaver allograft to
bilateral lower legs & anterior left thighs
Day 70: STSG with staple fixation 3375 sq cm bilateral lower extremities &
replacement of allograft with staple fixation 450 sq cm left thigh
Day 77: Removal & replacement of allograft along with non-selective
debridement of his left thigh followed by allograft replacement 750 sq cm with
staple fixation
Day 84: STSG to LLE, penis & scrotum
Nutrition Notes:
Assessments x 17
Follow-Up Notes x 4
Enteral Nutrition Notes x 3
Initial Assessment
History: Patient intubated, family unavailable, per admission nutrition screen, no decreased intake or involuntary weight loss PTA.
Relevant labs: Low serum magnesium; pt given IV magnesium sulfate. Glucose at 156 mg/dL.
Medications: ascorbic acid 500 mg 2x/day, magnesium sulfate once, multivitamin with mineral 1x/day, polyethylene glycol, ranitidine,
senna-docusate, fentanyl, lactated ringers.
Weight History: 6, BMI approx. 37 using admission weight (w/ 2+ BUE & BLE edema), therefore IBW of 80.5 kg will be used to calculate
energy/protein needs.
Nutrition Orders: Strict NPO with TF.
Goal EN: Promote with Fiber at 125 mL/hr provides 3000 kcal, 187 g protein, & 2490 mL free water with total volume of 3000 mL in 24 hours.
Enteral Access: DHT with tip in stomach.
Estimated Energy & Protein Needs:
4000-4400 kcal/day (25-30 kcal/kg + 40 x %TBSA)
160-200 g/day (2.0-2.5 g/kg)
Diagnosis: Predicted suboptimal energy intakerelated toneed for mechanical ventilation and increased nutrient needs for burn healingas
evidenced byplacement of DHT and initiation of EN and 58% TBSA burn.
Goal: Pat to receive 85% of enteral nutrition goal volume.
Interventions/Recommendations:
Enteral Nutrition: Current regimen does not meet estimated needs. Recommend changing to Impact Peptide 1.5 (concentrated formula with
immunonutrients). Goal rate would be 115 mL/hr, which would provide 4140 kcal, 259 g protein, and 2125 mL free water in a total volume of
2760 mL in 24 hours.
Labs: Monitor electrolytes, Mg, and phos daily until stable WNL, supplementing as needed.
Medications:
If EN regimen changed to Impact Peptide 1.5 , recommend starting guar gum 1 packet TID, as Impact Peptide 1.5 does not contain fiber.
Given burn size >25%, start glutamine BID and Oxandralone BID.
Recommend indirect calorimetry to better assess energy needs.
Day 1-8: Tube feeds started on Day 1 with Promote with Fiber at 20
mL/hr, advanced to 100 mL/hr on Day 2 before changing to Impact
Peptide 1.5 to better meet nutrition needs. Impact Peptide was
advanced to goal rate of 115 mL/hr later that day.
Average EN intake 2541 kcal and 159 g protein, meeting 64% low end of
estimated energy needs and 100% protein needs (2 g/kg IBW).
Per recommendations to primary service, Glutamine & Oxandralone
started 2x/day.
Patient extubated day 6.
Day 9-15: Average intake 3265 kcal and 204 g protein, meeting 81%
low end of estimated energy needs and 100% of protein needs (2.5 g/kg
IBW).
Bowel regimen decreased, guar gum packet added 2x/day due to high
stool output.
Day 16-23: Average EN intake 3625 kcal and 175 g protein, which
meets 91% low end of estimated energy needs and 100% of estimated
protein needs (2.2 g/kg IBW).
Failed swallow evaluation on Day 16.
Tube feeding formula changed to Osmolite 1.5 on Day 16 due to high
BUN/Cr.
Recommend d/c glutamine (> 12 days).
Day 24-31: Average intake 3513 kcal and 146 g protein daily, meeting
88% low end of estimated energy needs and providing 1.8 g/kg IBW
protein.
Failed swallow evaluations again on Day 24 and Day 25.
Dysphagia noted to be improved on swallow evaluation on Day 27.
Patient cleared for dysphagia advanced diet and thin liquids on Day 28
following VSS.
Day 33-52: Average intake 3432 kcal and 143 g protein, meeting 78%
of estimated energy needs and providing 1.8 g/kg IBW protein.
TF held for OR & for DHT replacement.
Patient consuming 100-200 kcal/day.
Day 53-77: Patient meeting 90-100% of estimated energy needs &
100% of estimated protein needs.
Tube feeds continue to be main source of nutrition. Patient consuming
200-300 kcal/day.
Day 78-91: EN + po intake now meeting > 100% of estimated needs
at 4639 kcal & 223 g protein (2.8 g/kg).
PO intake increased, mostly cold fruit & protein powder brought in from
home, to 600-700 kcal & 30-80 g protein.
Day 92-99: EN + po intake now meeting ~ 120% of estimated needs
with > 5000 kcal/day and 4.3 g/kg protein.
TF decreased to 16 hour cyclic feedings.
PO intake approx. 1700 kcal and 240 g, continues to consume protein
powder from home, but meal intake improving.
Day 100+
DHT out since day 103 with episode of emesis.
Needs met via oral nutrition after some encouragement
Estimated needs via IC 3056 kcal
160-200 g protein
Indirect Calorimetry Measurements
Day
REE
RQ
10
2193
0.86
47
2931
0.96
58
2336
0.91
72
3049
0.93
87
3357
0.89
101
3056
0.93
References:
