1. Nutritional Needs of the Burn Patient Joan LeBoeuf, RD, CNSD UNM Burn Center Adult & Pediatric Injury from tragedy… hope!

2. Topics of Discussion Kcal Needs Protein Needs Micronutrient Supplementation Methods of Nutrient Delivery Nutritional Monitoring UNM Burn Center : from tragedy… hope!

3. 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

4. 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

5. Determining Kcal Needs Calculation of energy needs for the burn patient remains challenging –% TBSA –Degree of burn –Other trauma involved

6. 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)

7. 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

8. 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

9. 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

10. 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

11. 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.

12. Micronutrient Guidelines After Thermal Injury Children ( 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.

13. 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

14. 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)

15. 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

16. 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

17. 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

18. 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

19. 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

20. Conclusions An aggressive nutrition approach for the burn patient is indicated to: –address hypermetabolism –enhance nitrogen retention –support wound healing –improve survival

21. 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.

22. Questions… one child burned, is one child too many! Joan LeBoeuf, RD, CNSD UNM Burn Center Adults & Pediatrics from tragedy… hope!