Determining the effects of peri-procedural fasting in Burn patients: are we meeting nutritional goals and does this affect patient outcomes? Stephanie Joyce MD

Significance Thermal injuries are associated with the greatest metabolic demand Early enteral nutrition improves outcomes, wound healing rates, reduced length of stay and reduced complications  EAST guidelines recommend starting enteral nutrition as soon as possible after admission and patient’s should receive at least 80% of recommended daily intake 

Preliminary studies Enteral feeding during operative procedures in Thermal Injuries – Journal of Burn Care and Rehabilitation.  1994 study, included 80 patients. 40 had enteral nutrition continued through the OR via post-pyloric feeding tubes and 40 had enteral nutrition with-held.  No patient in either group experienced aspiration.  The unfed group demonstrated a significant caloric deficit (p < 0.006) and increased incidence of wound infection (p < 0.02) 

Recent Publications  2017 Study from University of Massachusetts looking at Intra- operative feeding  Burn protocol included:  feeding tube placement, initiation of enteral tube feeding within 24 hours of injury, tube feeds are continued intra-operatively for patients with a secure airway  Patients with secure airways (ETT or Tracheostomy) with post- pyloric feeding tubes were included 17 patients received intra-operative feeding, 16 patients did not  No intra-operative aspiration or regurgitation events were recorded

EAST Practice Management Guidelines

Study – Data Collection Retrospective review of all patients admitted to the Burn ICU sustaining > 20% TBSA burns since 2012 Data was collected on intubated patients who required > 1 operation while intubated/trach'd   Total daily TF volume on OR days and non-OR days  Whether TF where held for OR  Type of tube and location  Aspiration events 

Results 45 patients were included Years 2012-2016 Daily % of calculated goal met No safety events noted between patients being fed through the OR and those with tube feeds held (including no documented aspiration events)  TF Held OR day Avg - % caloric needs met TF Held Non-OR day Avg TF Not Held OR  day Avg TF Not Held Non-OR day Avg 43% 76% 64%  74% 

TF Held OR day Avg - % caloric needs met TF Held Non-OR day Avg TF Not Held OR  day Avg TF Not Held Non-OR day Avg 43% 76% 64%  74% 

Next Step Collect prospective data starting in July Goal – meet 80% of calculated caloric needs on both OR days and non-OR days  Continue TF intra-operatively on patients with ESTABLISHED airways who are not undergoing airway surgery or prone positioning 

Feeding Through the OR Intubated/Trached Patient Yes No Yes Patient having airway surgery, prone positioning, or upper GI surgery Hold TF at 1:30 AM Hold TF at 1:30 AM No Continue TF. Ensure accurate recording of TF intake prior to OR and then zero pump on call to the OR

References · Jenkins M, Gottschlich M, Warden G. Enteral feeding During Operative Procedures in Thermal injuries. Journal of Burn Care & Rehabilitation, 1994; 15(2): 199-205. · Jacobs D, Jacobs D, Kudsk K, Moore F, et al. Practice Management Guidelines for Nutritional Support of the Trauma Patient. Journal of Trauma, 2004; 57:660-679. · Taylor B, McClave S, Martindale R, Warren M, et al. 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 of Parenteral and Enteral Nutrition (A.S.P.E.N.). Soceity of Critical Care Medicine Journal, 2016; 4(2): 390-438. · Passier R, Davies A, Ridley E, McClure J, Murphy D, Scheinkestel C. Periprocedural cessation of nutrition in the intensive care unit: opportunities for improvement. Intensive Care Medicine, 2013; 39: 1221-1226. · McElroy L, Codner P, Brasel K. A Pilot Study to Explore the Safety of Perioperative Postpyloric Enteral Nutrition. Nutrition in Clinical Practice, 2012; 27(6): 777-780. · Parent B, Mandell S, Maier R, Minei J, Sperry J, Moore E, O’Keefe G. Safety of minimizing preoperative starvation in critically ill and intubated trauma patients. Journal of Trauma and Acute Care Surgery, 2016; 80(6): 957-963. · Shields B, Brown J, Aden J, Salgueiro M, Mann-Salinas E, Chung K. A pilot review of gradual versus goal re-initiation of enteral nutrition after burn surgery in the hemodynamically stable patient. Burns, 2014; 40: 1587-1592. · Czapran A, Headdon W, Deane A, Lange K, Chapman M, Heyland D. International observational study of nutritional support in mechanically ventilated patients following burn injury. Burns, 2015; 41: 510-518. Varon D, Freitas G, Goel N. Intraoperative Feeding Improves Calorie and Protein Delivery in Acute Burn Patients. Journal of Burn Care and Research, 2017; Published ahead of Print.