BURN

NUTRITIONAL
MANAGEMENT
PROTOCOL

Kingdom of Saudi Arabia

Ministry of health
Health affairs of hail region
King Salman Specialist Hospital Burn Nutritional Management Protocol
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 Contents:
1. Introduction …………….…………………................................................... 3
2. Protocol Purpose ……………………….…….............................................. 3
3. Nutritional management goals ………………………………………..…………... 4
4. Nutrition Care Process of burn patients……………..................…………..4
4.1 Nutrition Assessment ………………………………………………..……….……4
4.2 Nutrition Diagnosis ……….………………………………….……………………..5
4.3 Nutrition Intervention ……………………………………………..………………5
4.3.1 Determine nutrient requirements …………...............…..…5
[Link] Calorie ………………………………………………..………...……5
[Link] Protein ………………..…………..…………………………...……8
[Link] Fat ……………………………………………….…………….....……9
[Link] Fluid ……………………………………..…………………….………9
[Link] Micronutrient ……………………………………..………...… 10
4.3.2 Determine Management according to severity ………………11
4.3.3 Determine nutrition support mode ………..………………….…11
[Link] Enteral Feeding ………………………………………………… 11
[Link] Parenteral Feeding …………………………………………….12
[Link] Dual Feeding ……………………………………………………..14
[Link] Types of Formula ……………….……………………………..15
[Link] Peri and Post-operative nutrition support …..…….15
[Link] Complications of nutrition support ………….…….….16
4.4 Nutrition Monitoring & Evaluation ………….………………………….….17
5. Nutrition after discharge ………….....................................................19
6. Burn nutrition flow chart ………….....................................................20
References …………..............................................................................21

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 1. Introduction:

Major burns result in severe trauma. Energy requirements can increase as much as
100% above resting energy expenditure (REE), depending on the extent and depth of
the injury (see Figure 38-7). Exaggerated protein catabolism and increased urinary
nitrogen excretion accompany this hypermetabolism. Protein is also lost through the
burn wound exudate. Burn patients are particularly susceptible to infection, and this
markedly increases their requirements for energy and protein. Because patients with
major burns may develop an ileus and be anorexic, nutrition support therapy can be a
real challenge. Children's healing after burns and trauma requires not only restoration
of oxygen delivery and adequate calories to support metabolism and repair but also
awareness of how children differ from adults in metabolic rate, growth requirements,
and physiologic response. (1)

2. Protocol Purpose:

The Clinical Dietitians at King Salman Specialist Hospital have collaborated to develop
the following protocol in order to clarify the role of the dietitian in the multidisciplinary
burns team in the burns unit. Their role in the assessment, treatment, and management
of nutrition problems arising from burn and inhalation injuries is crucial. They designed
it as a practical guide to the relevant clinical knowledge and dietary intervention
required for effective burn management.

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 3. Goals of nutritional support in critical burn patients include:

 Lean body mass must be maintained

 Prevent starvation and avoid establishment of specific nutrient deficiencies
 Hasten good wound healing
 Prevention, control of infections, and management of established infections
 Visceral and somatic protein loss must be restored
 Enteral and parenteral nutrition-related complications must be prevented
 Stress response and complications must be attenuated or modulated with
adequate and appropriate quantities of required nutrients

4. Nutrition Care Process for burn patients:

4.1 Nutrition assessment:

Initial assessment of all patients with severe burn injuries is mandatory and should be
made on admission to hospital to form a baseline data for knowing the progress made
throughout the therapy and must be initiated within the first 24, (2) 24–48h (3) of burn
injury.

Nutrition assessment should include:

- Height and pre-burn weight. (Fluid resuscitation can cause significant edema and alter the
weight measurements)
- Details of pre-burn nutritional status
- Current Gastrointestinal function
- %TBSA of burn
- Site of injury (around oral cavity and hands)
- Pre-existing medical conditions
- Usual diet and any food allergies (3)

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 4.2 Nutrition Diagnosis:

The nutritional diagnosis of burn patients depends on the severity of burn and its effect
of the nutritional states. In spite of the fact that dietitians are not responsible for
assessing the severity of the burn and the assessment is made by an experienced
medical/surgical team to avoid over or under estimations, they have to know when the
patient considered to have severe burn.

The following are some examples of severe burns:

- Partial/ full thickness burns in adults >10% TBSA.

- Partial/ full thickness burn in children > 5% TBSA.
- Burns to the face, hands, feet, genitalia, perineum, or major joints.
- Chemical burns
- Electrical burns
- Burns with concomitant trauma.
- Burns with inhalation injuries
- Burns with pre-existing medical disorders which may adversely affect care or
outcomes.

 Adults with a burn greater than 20% of TBSA likely to have significant
hypermetabolism. They are unlikely to be able to meet their nutrition requirements
orally.

4.3 Nutrition Intervention:

4.3.1 Determine nutrient requirements for burn patients:

[Link] Calories requirements

Based on expert consensus, Indirect Calorimetry is the most accurate means to assess
energy needs. In situations where IC is not available, various published predictive
equations can be used (Table 1) but due to the fluctuation of energy expenditure after
burn, using a fixed formula often lead to underfeeding during periods of highest energy
utilization and to overfeeding late in the treatment course. So, a number of formulas
could be used to provide a range of estimated requirements and energy requirements
should be reassessed on a regular basis.

In the absence of IC, the Toronto equation considered as a well validated alternative for
adult. For children, the Schofield equation appears as a reasonable alternative, while

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 keeping in mind it might underestimate the requirements, and that the result of the
calculation should be rounded upwards. (2)(3)(5)

When to re-assess calories needs: Weight gain is common during the resuscitation
phase. The fluids are generally mobilized slowly over the next 2 weeks to 1month
period as the wounds heal and the patient recovers. Therefore, as the weight begins to
trend downward and the wounds are being closed, it is important to reassess calories
and protein requirements. Weight of the patient is monitored closely. There should not
be a fall of more than 10% below baseline weight and also should not gain excessive
weight. (3)

Table 1 Common formulas used to calculate caloric needs of burn patients

Adult Kcal/day Comments
Harris Men: 66.5 + 13.8(weight in kg) + 5(height in cm) − 6.76(age Estimates basal energy
Benedict in years) expenditure; can be adjusted
Women: 655 + 9.6(weight in kg) + 1.85(height in cm) − by both activity and stress
4.68(age in years) factor, multiply by 1.5 for
Injury % <10 11-20 21-30 31-50 50 + common burn stress
Factor:
Burn adjustment
1.2 1.3 1.5 1.8 2.0
Toronto REE (kcal) = -4343 + (10.5 x TBSA burned) + (0.23 x kcals) Useful in acute stage of burn
Formula + (0.84 x Harris Benedict) + (114 x T (o C)) - (4.5 x days' care; must be adjusted with
post-burn) changes in monitoring
TBSA = total body surface area burned; parameters
kcals = calorie intake in past 24 hours;
Harris Benedict = basal requirements in calories using the Harris
Benedict equation with no stress factors or activity factors;
T = body temperature in degrees Celsius;
days post-burn = the number of days after the burn injury is
sustained using the day itself as day zero.
Davies and 20(weight in kg) + 70(TBSA) Overestimates caloric needs
Lilijedahl for large injuries
Ireton-Jones Ventilated patient: 1784 − 11 (age in years) + 5 (weight in Complex formula which
kg) + (244 if male) + (239 if trauma) + (804 if burn) Non- integrates variables for
ventilated patient: 629 − 11 (age in years) + 25 (weight in ventilation and injury status
kg) − (609 if obese)
Curreri Age 16–59: 25(weight in kg) + 40(TBSA) Often overestimates caloric
Age >60: 20(weight in kg) + 65(TBSA) needs
Pediatric formulas
Schofield Boys
3-10 y: (19.6 x weight in kg) + (1033 x height in cm) +
414.9
10-18 y: (16.25 x weight in kg) + (1372 x height in cm) +
515.5

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 Girls
3-10 y: (16.97 x weight in kg) + (1618 x height in cm) +
371.2
10-18 y: (8365 x weight in kg) + (4.65 x height in cm) +
200
Galveston 0–1 year: Focuses on maintaining body
2100(body surface area) + 1000(body surface area × TBSA) weight
1–11 year:
1800(body surface area) + 1300(body surface area × TBSA)
12–18 years:
1500(body surface area) + 1500(body surface area × TBSA)
Curreri junior <1 year: recommended dietary allowance + 15(TBSA) Commonly overestimates
1–3 years: recommended dietary allowance + 25(TBSA) caloric needs
4–15 years: recommended dietary allowance + 40(TBSA)
*TBSA total body surface area

Hypermetabolic State in Burn Injuries:

Hypercatabolism is characteristized by the following features in a patient with 25% burns:

1. Metabolic rate in an adult patient is elevated to as high as 118%–210%.

2. Approximately 180% rise in resting metabolic rate.
3. Calorie need exceeds 5000 kcal/day.
4. The patient with 40% burn injury loses 25% of preadmission weight within 3 weeks'
time without nutritional support.
5. Impaired immunity and delayed wound healing. (3)

Overfeeding

Overfeeding of burned patients can lead to major complications. For example,

carbohydrate overfeeding may result in elevated respiratory quotients, increased fat
synthesis, and increased CO2 elimination. Moreover, overfed ventilated patients
become more difficult to manage or wean from ventilator support. Excess
carbohydrates or fat can also lead to fat deposition in the liver and excess protein
replacement to elevations in serum urea nitrogen. In addition, overfeeding can augment
hyperglycemia, which can be difficult to treat as both endogenous and exogenous
insulin effects are often countered by the surge of catabolic hormones. (2)

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 [Link] Protein requirements

Supplying high doses of protein does not reduce the catabolism of endogenous protein
stores, but it does facilitate protein synthesis and reduces negative nitrogen balance.
The 2001 American Burn Association guidelines, the 2013 ESPEN guidelines and the
2016 ASPEN guidelines all recommended the provision of 1.5–2 g of protein/kg/d for
adult patients with burn injury. And 2.5–4.0 g/kg/day for burned children. Even at these
high rates of replacement, most burn patients will experience some loss of muscle
(2)(5)
protein due to the hormonal and proinflammatory response to burn injury. Sever
burn increase skeletal muscle and organ efflux of glutamine, alanine, and arginine.
These amino acids play a unique role in recovery after burn, wounds healing and supply
energy to the liver.

% Burn Protein/kgBwt/d NPC:N ratio

<15 1.0-1.5 150:1
15-30 1.5 120:1
31-49 1.5-2 100:1
50+ 2-2.3 100:1
Glutamine:
The use of glutamine in burn treatment is currently being examined in burn patients,
but dosages and administration have not been clarified. One recommendation is 0.3
g/kg/day for the first 5–10 days' post-injury. This amount is consistent with dosages
studied in other critically ill populations. (10)
Arginine
The supplementation of arginine in burn patients has led to improvement in wound
healing and immune responsiveness. Arginine stimulates T lymphocytes, augments
natural killer cell performance, and accelerates nitric oxide synthesis, which improves
resistance to infection. Despite some promising results in the burn population, data from
critically ill nonburn patients suggest that arginine could potentially be harmful. The
current data is insufficient to definitively recommend its use, and further study is
warranted. (2)

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 [Link] Carbohydrates requirements
The number of recent studies investigating carbohydrate requirements in burns is
limited. A few sophisticated isotopic studies conducted in adult and pediatric burn
patients and recent reviews and guidelines enable recommending to deliver 55-60% of
energy as carbohydrates without exceeding 5 mg/kg/min both in adults and children:
this number corresponds to 7 g/kg/day in a standard adult patient. (8)

[Link] Fat requirements

Fat is a required nutrient to prevent essential fatty acid deficiency, but it is
recommended only in limited amounts (no more than 25-30% as energy) but in fact 15-
20% of non-protein energy as fat is optimal. (2)(4)

[Link] Fluid requirements

Fluid requirements are determined by the Medical Burn Team using the Parkland
Formula as it is the basis of burn resuscitation and treatment. The Dietitian only needs
to document the total amount of fluids the patient is receiving via artificial nutrition,
and to inform the Team of this amount. (4)


The Parkland formula for the total fluid requirement in 24 hours is as follows: (4)
4ml x %TBSA x kg

50% given in first eight hours

50% given in next 16 hours


Children receive maintenance fluid in addition, at an hourly rate of: (6)
4ml/kg for the first 10kg of body weight plus

2ml/kg for the second 10kg of body weight plus

1ml/kg for >20kg of body weight

 End point
Urine – adults: 0.5–1.0 ml/kg/hour

Urine – children: 1.0–1.5ml/kg/hour

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 [Link] Micronutrient requirements

Micronutrient requirements must also be considered post-burn as protein and energy

cannot be effectively utilized if micronutrient intakes are inadequate. Trace elements
such as zinc and copper are lost in exudate from the burn wound and selenium and iron
may be lost during surgical procedures such as excision and grafting. Urinary losses of
trace elements also increase. Replacement of these micronutrients has been shown to
improve the morbidity of severely burned patients by enhance immunity, wound
healing, protein and collagen synthesis. Certain vitamin requirements are also
increased, for example:

- Vitamin C is necessary for collagen synthesis and immune function

- Vitamin A is required to decrease time of wound healing via epithelialization
and maintenance of the immune response
- High energy intakes also lead to an increased demand for B vitamins.
Additional vitamins and minerals are therefore necessary to replace losses and meet
increased requirements for wound healing but consideration of possible interaction
between micronutrients is important when supplementing with high doses. For
example, high doses of zinc supplements may lead to copper deficiency. Demling and
Seigne (2000) outline certain recommendations for micronutrients (Table 2). However,
more research is required in this area. (2)(3)(4)

Table 2
Daily requirements of vitamins and minerals
Vitamin Specific component Daily dose
Vitamin B complex Thiamine 10 mg
Riboflavin 10 mg
Niacin 200 mg
Folate 2 mg
Vitamin B12 20 mg
Vitamin C 2g
Minerals Selenium 100 m
Copper 2-3 mg
Zinc 50 mg
Manganese 25-50 mg

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 4.3.2 Determine Management according to severity

Management of Non-Severe Burn

Adults with burns less than 20% of TBSA may be able to meet their requirements
orally. They are encouraged to eat and drink as soon as possible following the injury.
Intake is monitored and the diet reviewed as necessary. Enteral feeds may be needed if
oral intake is inadequate. Adults with burns to the face, airway or hands may need closer
nutritional monitoring to ensure they have the ability to eat and drink. (4)

Management of severe Burn

Adults with burns greater than 20% of TBSA likely to have significant
hypermetabolism. They are unlikely to be able to meet their nutrition requirements
orally and they need to assessed for nutrition support. (4)

4.3.3 Determine nutrition support mode

In the treatment of severe burns, major determining factors of success are the
installation of an adequate nutrition route and a subsequent nutrition regimen. Nutrition
methods that involve oral alimentation are often unsustainable because of the frequency
of altered mental status, inhalation injuries, endotracheal intubation, GI dysfunction,
and feeding intolerance seen in burned patients. Even in the absence of these factors,
studies have shown that the use of oral alimentation alone is not ideal, as it can allow
patients with 40% TBSA burns to lose up to a quarter of their preadmission weight by
21 days' post injury. Oral feedings in severely burned patients are also difficult to
sustain because of the large and often intolerable amounts of food necessary to manage
severe catabolism. (7)

The following criteria are followed in Burn Nutrition:

 Enteral
 Parenteral
 Dual Feeding (Enteral/Oral-Enteral/Parenteral) (4)

[Link] Enteral Feeding

 Early enteral feeding within the first 24–48 hours is the preferred mode of
artificial feeding over total parenteral nutrition (TPN), delivered in a continuous
delivery mode over 24 hours, and should be maintained while patients remain

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 in the flow or catabolic phase regardless of their state of oral intake. ASPEN
suggests very early initiation of EN if possible, within 4–6 hours of injury.
(Indicators of the flow phase include Tachycardia, Hypertension and
(3)(4)
hyperventilation). The use of nasojejunal feeding is recommended in
patients that fail nasogastric feeding due to gastric stasis or persistent vomiting.
Nasojejunal feeding has been supported as a safe and well-tolerated method of
feeding in other critically ill patients and in patients with severe burn injury.
The use of trans-pyloric feeding tubes allows commencement of enteral
nutrition within 24 hours of admission and can be continued during surgery to
ensure continuous caloric and protein supply. (4)
 Early nutrition supplementation in burned patients is associated with less time
taken to achieve positive nitrogen balance and lower plasma glucagon
concentrations during the first two weeks of enteral nutrition. This reduces
caloric deficits and may stimulate insulin secretion and protein retention.
Additional benefits are maintenance of mucosal integrity; a decreased incidence
of diarrhea and a decreased length of hospitalization are also supported. Early
enteral feeding may decrease intestinal permeability, preserve the intestinal
mucosal barrier, and reduce enterogenic infection. Delayed enteral feeding (>18
hours) results in a high rate of gastroparesis and a need for intravenous nutrition.
(4)(5)

[Link] Parenteral nutrition

 Parenteral nutrition may be difficult to implement and to maintain because of

extensive skin loss and the risk of the potential complications of septic and
thrombotic complications. As parenteral nutrition is less effective in
maintaining the gut barrier and host immune function than enteral feeding, use
of parenteral nutrition in the case of a functioning gut is not justified. Patients
who do not tolerate enteral feeding should have total parenteral nutrition started
immediately while continuing attempts are made to reestablish enteral nutrition.
Parenteral nutrition would be administered in consultation with the TPN
pharmacist. (2)(4)

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 Central Parenteral Nutrition

 Central venous catheters are widely used to administer parenteral nutrition,

especially in long-term nutrition. As hyperosmolar solutions are harmful to the
intima of the veins, central veins with high blood flow enable hyperosmolar
solutions to be given, such as glucose and amino acid solutions. This enables
nutritional requirements to be given in smaller volumes than is possible with
peripheral parenteral nutrition. Severe complications that may occur during
central venous infusion of parenteral nutrition include sepsis, air embolism, and
thrombosis, with these complications more likely to occur compared with the
infusion of parenteral nutrition peripherally. (4)

Peripheral Parenteral Nutrition

 Patients who require 10 days of nutritional supplementation and who can't

consume these calories via oral or enteral route. This can be used as a bridge to
maintain adequate caloric intake while advancing enteral. The limitation of
peripheral nutrition is that only lower osmolarity solutions can be given to avoid
thrombophlibitis and fluid overload. Thus Peripheral parenteral nutrition is not
the optimal access route in situations of severe metabolic stress, where there are
large nutrient or electrolyte needs (especially potassium, which is a strong
vascular irritant), with fluid restrictions or if prolonged intravenous nutrition is
required. It is appropriate to use peripheral nutrition as a supplement to enteral
intake to ensure adequate nutrition support. (4)

TPN administration guidelines (10)

Nutrient Recommended intake Key elements of care
Total solution 1.75 mL/kg/h for infants and TPN can be initiated at goal
children <20 kg, 1.5 mL/kg/h rate. Adults and older
for >20 kg children (>50 kg), may need
to begin at 75% goal rate if
hyperglycemic prior to
initiation
Carbohydrate 5–7 mg/kg CHO/min Maximum rate of glucose
oxidation isotopically
determined in younger and
older burned children and
adults

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 Protein 2.5–4.0 g/ kg IBW High amino acid content
enables protein goal to be
met without excessive
volume
Fat (20% intralipid) Initiate at 0.5 g/kg for 12 h. Patients on TPN >14 days
Goal volume: 1.0–1.5 g fat/ not receiving enteral
kg/day. Intralipids are not be feedings (Note: intralipid
administered in doses: >3.6 may not be indicated in
g/ kg/day patients receiving propofol).
Propofol contains a 10%
soybean oil solution and
therefore provides essential
fatty acids and additional
calories (1 kcal/mL).
Triglyceride levels are
monitored at baseline and
weekly. Lipids are held for
levels >350 mg/dL
Biochemical monitoring of patients on TPN
Measurement Acute Acute, non-stressed Non-acute
Electrolytes Daily Semi-weekly Daily for 3 days;
weekly
Phos, Mg, iCa Semi-weekly Semi-weekly Weekly
LFT’s, Alb, TP Weekly Weekly Biweekly
Pre-albumin, CRP Weekly Weekly Weekly

[Link] Dual Feeding

Enteral/ Parenteral
Parenteral Nutrition should be given when enteral nutrition fails to meet nutritional
requirements. The early use of parenteral nutrition ensures estimated nutritional
requirements are met. (4)

Enteral/ oral
Oral feeding should be encouraged as soon as patient is enabled to eat and drink.
Patients sustaining an inhalation injury need Speech Therapy assessment before
introduction of any oral substances. The Oral diet must constitute high protein and
energy choices, in similar proportions to the above requirements. High protein
supplements are manipulated to increase protein further as per requirements.

Enteral feeding given in combination with oral intake of food and having an optimally
balanced ratio of nutrients as found in commercial enteral formulas assists in
normalizing metabolic processes as early as possible after burn injury through
inhibition and reduction in catabolic processes, stabilization of biological membranes
and encouragement of anabolic processes. Supplementary enteral feeding used in

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 conjunction with oral intake should continue until all abnormal metabolic processes
have been normalized as the burn patient's metabolism remains elevated until wound
coverage and healing are complete. This results in an improved general clinical
condition and the most efficient surgical treatment of wounds. (4)

[Link] Types of Formula

Standard Polymeric formula which contain high CHO, high protein and low fat are
most common and beneficial in burn for maintaining lean body mass and wound
(8)
healing. Although there are many theories and promising research into nutritional
immunomodulators formula that containing glutamine, arginine and ω-3 fatty acids.
Early studies supported the inclusion of arginine, and glutamine as conditionally
essential amino acids in burns patients. A recent meta-analysis has recommended the
use of glutamine supplemented enteral nutrition in burns patients. Reductions in
mortality and infectious complications have been shown. However, the role for arginine
remains controversial and the same meta-analysis did not recommend using enteral
formulas supplemented with arginine in the critically ill due to the potential for
increased mortality in septic patients. Further research is required in this area. (2)(3)(4)

[Link] Per and Post-operative nutrition support

Peri-operative nutrition support

Burn patients may be malnourished prior to surgery, with malnutrition an important

determinant of increased post-operative illness, complications, and mortality in surgical
patients. Nutrition intervention in the pre-surgical patient aims to prepare and replenish
nutrient reserves if the patient is malnourished for the post-operative period, where
nutritional requirements are increased due to factors which include stress and wound
healing. It is important to consider that many hospitals ‘fast’ patients as standard from
12 midnights the night prior to surgery. This can mean that many burn patients, who
are on evening surgical lists, are repetitively without nutrition for over 12 hours at a
time, furthering their risk of malnutrition and delayed wound healing.

Supportive per-operative nutrition should be considered as a crucial part of the patients’

treatment. Enteral feedings can be continued throughout excision and grafting
procedures with close monitoring required of feeding tube placement and gastric reflux

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 during surgery. If feedings are ceased, resumption of the enteral feeding regime post-
surgery is a priority, with the aim of minimizing the number of hours lost to enteral
feeding post-surgery. Continuous enteral nutrition throughout the operative and per-
operative period via a nasojejunal tube has been shown to be feasible, safe, and
clinically effective with reduced infection rates and increased caloric intake.
Continuation of enteral feeding during these periods should be discussed and agreed
with the surgical and anaesthetic teams. (4)

Post-operative nutritional support

Post-operative nutrition intervention objectives are to replenish protein and glycogen

stores, vitamins, minerals, protein, and iron lost through blood loss and prevent
infection. Provision of a high-energy, high-protein diet is the most effective nutrition
intervention in both burn and surgical patients. The diet regime recommended is an oral
intake of a high energy, high protein diet supplemented with a high energy/high protein
formula provided enterally (nasogastric or naso-jejunal tube), or parenterally
(peripheral or central line). (4)

[Link] Complications (4)

Complications Possible causes: Management:

Aspiration - Delayed gastric emptying - Place a nasoenteric tube past the
- Tube dislodgement or Ligament of Treitz
incorrect positioning - Change to a fine bore tube (10-
- Use of a large bore 12F)
nasogastric tube (>14 F) - Decrease feed rate by 10-
- Use of medications 20ml/hour
affecting gut motility such - Consider use of a prokinetic
as opiates agent
- Positioning of patient - Elevate bed head at least 450

Vomiting - Tube positioning - Correct tube positioning

- gut immotility - assess feed for modification
- use of opiates - decrease feed rate by 20-30mls
- intracranial pressure - elevate bed head at least 450
- respiratory status - consider use of a prokinetic
- feeding rate too fast agent or reassess type already in
- hyperosmolar feed use
- obstruction

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 - consider fine bore nasoenteric
tube placed past Ligament of
Treitz – transpyloric feeding

Constipation - Dehydration - Monitor fluid intake and output

- Concentrated formula – check is meeting fluid
- Insufficient fibre requirements
- Effect of pain killers – - change to a fibre containing feed
opiates or use a fibre supplement.

Dehydration - Inadequate fluid intake - Review total fluid intake

- Concentrated feed - include water flushes
- Diarrhoea - For management of diarrhoea
see above.

4.4 Nutrition Monitoring & Evaluation

Monitoring

It is challenging to objectively assess the success of nutritional intervention in a burn

patient as the true endpoint of therapy is global and cannot be measured by one variable.
The main goal of therapy is to get the body's composition and metabolism back to
normal. Common things that are measured are body weight, nitrogen balance, imaging
of lean body mass, and serum protein levels (Table 3).

Body weight is a tempting measure of nutritional status as it is easy to obtain and is

useful in the general population. However, it can be very misleading in burn patients.
The initial fluid resuscitation after severe burns routinely adds 10–20 kg or more of
body weight, and although this will eventually lead to diuresis, the time course is
unpredictable. Additional fluid shifts occur with infections, ventilator support, and
hypoproteinemia, making body weight a very unreliable gauge of nutrition in this
population. Patients can have increased total body water for weeks after the burn, which
can mask the loss of lean body mass that has certainly occurred. Long-term trends are
valuable, and weight should be monitored, especially during the rehabilitation phase.
Providing adequate protein intake is an extremely important part of nutritional support
after burns. Nitrogen is a fundamental component of amino acids, and as such, the
measurement of nitrogen inputs and losses can be used to study protein metabolism. A
positive nitrogen balance is associated with periods of growth as it represents an
increase in the total body amount of protein, while a negative nitrogen balance occurs

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 with burns, trauma, and periods of fasting. Graves et al. surveyed 65 burn centers in
2007 regarding their nutritional monitoring practices, and the most commonly used
parameters were prealbumin (86% of centers), body weight (75%), calorie count (69%),
serum albumin (45.8%), nitrogen balance (54%), and transferrin (16%). No individual
method is universally reliable or applicable for the nutritional monitoring of burn
(2) (4)
patients, and the overall clinical picture must be incorporated into the assessment.

Table 3
Monitoring
Parameter Specific component Suggested Frequency
General Parameter Fluid Balance Daily while Acute then PRN
Blood Glucose Levels Daily while Acute then PRN
Vital sign (T/RR/HR/BP) Daily while Acute then PRN
Gastric Residuals Daily while Acute then PRN
Bowels Daily while Acute then PRN
Healing rate Daily while Acute then PRN
Functional parameters Daily while Acute then PRN
Nutrient intake (EN/PN/Oral) Daily while Acute then PRN
Weight Weekly ( without dressings)
Biochemical Urea & Electrolytes Daily
Parameter Serum Ca, PO4, Mg Every second Day
ABG’s Every second Day
Nutritional Markers Twice Weekly
e.g. pre-albumin
Inflammatory markers (CRP) Twice Weekly
LFT’s Twice Weekly

Evaluation

Reassessment of Nutrition Requirements

In adults, re-calculation of nutritional requirements using an equation should occur on

a routine basis as wound size, and thus metabolism changes with skin grafting, re-
epitheliazation and graft loss. Mechanical ventilation of a patient reduces the energy
required for breathing by up to 20%. In contrast energy and protein requirements may
increase during the recovery phase, when the patient’s activity level increases and
catabolism is replaced by anabolism. Weekly serum transferrin and prealbumin should
be tested, as they are indicators of visceral protein status. Both serum transferrin and
prealbumin are negative acute phase reactants and thus decline markedly in the acute
post burn phase. Monitoring C-reactive protein may provide an indication of the level
of inflammatory reaction and improve interpretation of visceral protein levels.
However, they are useful markers in the evaluation of nutritional status into
convalescence. (4)

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 Summary : Nutrition Care Process for burn patients

Nutrition Assessment
01

-pre-burn nutritional status Nutrition Diagnosis

-Previous medical conditions -Burn effects on nutritional
-Ht, pre-burn wt. state & intake
-Current GIT function
-Food allergies
-%TBSA of burn
-Site of injury Patient, Doctor &
Nurse interact 02
04 with dietitian

Monitoring & Evaluation

-Reassess requirement on Nutrition Intervention
a routine base -Determine nutrient
-Check general & requirements
biochemical parameter -Determine nutrition support
mode
-Determine Management
03
according to severity

5. Nutrition after discharge

It is important that patients continue to receive adequate nutrition after discharge from
the hospital, but data on the optimal diet after the acute postburn phase are virtually
nonexistent. Because the hypermetabolic state can persist for over a year after burn
injury, increased caloric intake with a high protein component is usually recommended
for about a year after discharge. Resistance exercise is also recommended to combat
continued loss of muscle mass. Patients should regularly weigh themselves to ensure
they are maintaining their weight as instructed by the physician and dietician.
Nutritional assessments should be a consistent component of outpatient follow-up for
burn patients. (2)

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 Burn nutritional management flow chart

Step 1
Assessment of Burns Patient

 Adults with 15% or greater total body surface area

(TBSA) burns (10% in children)
 Patients with inhalation injury
 Patients with poor Gastrointestinal function
If the patient  Those with poor nutritional status on admission If the patient
has nothing  Those on therapeutic diets has 1 or more
 Those whose intake is compromised by facial or hand
burns
 Patients with pre-existing medical conditions that
affects nutritional intake

(No need for consultation)

Order high calorie high
protein oral diet Diagnose the patient nutritionally
Step 2

 Is the patient at a high risk and has severe burn?

 Can not meet his requirement orally?

Yes, No,

assessed for nutrition support

(has a functional gut?) Order high calorie high protein
oral diet

includes mid-meal snacks

Yes, No, + nutritional supplements

Start EN early within the first

Start PN immediately while
24-48 hours.
continuing attempts are made to
If possible, within 4–6 hours reestablish EN
of injury.
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 References:
1. Mahan, L. K., & Raymond, J. L. (2016). Krause's food & the nutrition care
process-e-book. Elsevier Health Sciences.
2. Clark, A., Imran, J., Madni, T., & Wolf, S. E. (2017). Nutrition and metabolism in
burn patients. Burns & trauma, 5.
3. Natarajan, M. (2019). Recent concepts in nutritional therapy in critically Ill burn
patients. International Journal of Nutrition, Pharmacology, Neurological
Diseases, 9(1), 4.
4. A’Beckett, K., Baytieh, L., Carr-Thompson, A., Fox, V., MacLennan, P., Marriott,
J., ... & Petrunoff, N. (2011). NSW Statewide Burn Injury Service clinical practice
guidelines for burn patient nutrition management. NSW Agency for Clinical
Innovation, Sydney.
5. Taylor, B. E., McClave, S. A., Martindale, R. G., Warren, M. M., Johnson, D. R.,
Braunschweig, C., ... & Compher, C. (2016). Guidelines for the provision and
assessment of nutrition support therapy in the adult critically ill patient: Society of
Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral
Nutrition (ASPEN). Critical care medicine, 44(2), 390-438.
6. [Link]. 2020. [online] Available at:
<[Link]
uidelines_quick_reference_chart.pdf> [Accessed 25 March 2020].
7. Rodriguez, N. A., Jeschke, M. G., Williams, F. N., Kamolz, L. P., & Herndon, D.
N. (2011). Nutrition in burns: Galveston contributions. Journal of Parenteral and
Enteral Nutrition, 35(6), 704-714.
8. Rousseau, A.-F., Losser, M.-R., Ichai, C., & Berger, M. M. (2013). ESPEN
endorsed recommendations: Nutritional therapy in major burns. Clinical
Nutrition, 32(4), 497–502. doi: 10.1016/[Link].2013.02.012
9. Nelms, M., & Sucher, K. P. (2015). Nutrition therapy and pathophysiology.
10. Prelack, K., Dylewski, M., & Sheridan, R. L. (2007). Practical guidelines for
nutritional management of burn injury and recovery. burns, 33(1), 14-24.

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