Burn Patients: Review of Nutrition

Metabolic response to trauma

Immediately following injury, the patient will enter into the ebb phase for approximately 72
hours. During this phase, it is likely that the patient will experience hypovolemia, shock, tissue
hypoxia, a decrease in cardiac output, a decrease in oxygen usage, a reduction in body
temperature, and a decrease in insulin levels. The ebb phase is characterized by hyperglycemia
and hypometabolism.
Following the ebb phase, a patient will enter into a flow phase, occurring 3-5 days following
injury. The patient becomes hypermetabolic at this time. In this phase, cardiac output, oxygen
consumption, body temperature, and energy usage increase. The patient now will begin to
undergo protein and skeletal muscle catabolism. Hormone production shifts during the flow
phase. Glucose, free fatty acid release, insulin, epinephrine and norepinephrine, glucagon, and
cortisol levels will all increase. The levels of carbohydrate, protein, fat, and oxygen released
increases; however, usage is poor. Energy production is dependent on protein following a
traumatic injury. This will lead to extreme loss of lean body mass and negative nitrogen balance
until the cause of physiological stress is improved. The breakdown of protein also will lead to an
increase in urinary losses of potassium, phosphorous, and magnesium. The hormonal changes
that the patient undergoes following trauma will increase lipolysis, resulting in more circulation
of free fatty acids. Trauma patients will experience hyperglycemia as a result of increased
gluconeogenesis and the shift in hormone production, such as the increased production of
epinephrine. Aldosterone and vasopressin levels increase following traumatic injury, leading to
conservation of water and sodium. Serum iron and zinc levels decrease following injury.

Feeding the burn patient

The first 24-48 hours of nutritional intervention replaces lost fluid and electrolytes. The first 8
hours are the most critical for replacement; in fact, the patient should receive half of the amount
given within the first 24 hours during the first 8 hours. Following this immediate phase,
meticulous calculation of fluid still is required to provide for maintenance and to make up for the
evaporative losses from the wounds.
Evaporative water losses are calculated as:
2.0-3.1 mL/kg of body weight/percent total body surface area (TBSA) burn
Total fluid needs are often calculated by:
% TBSA burned wt (kg) x 2-4
Initiation of feeding is recommended within 4-12 hours of hospitalization. Introducing enteral
feeding within the first 6 hours of hospitalization is safe and effective, often reversing some of
the most important metabolic and hormonal effects of burns in a timely manner. Many patients
will need the enteral tube placed into the small intestine, because of risk of ileus, coupled with
impaired gut motility and risk of aspiration.
Calculation of energy needs is usually based on the Curreri method:
24 kcal kg usual body weight + 40 kcal % TBSA (with a maximum of 50% TBSA)

When using a different formula that does not designate a maximum percentage of TBSA, it is
important to note that the body usually is unable to handle more than two times the resting
energy expenditure (REE). Whenever possible, use indirect calorimetry, as many calculations
(including Curreri) seem to overestimate actual energy needs, especially for obese patients (some
research shows this overestimation to be as high as 34%). Adults are often calculated to need 3540 kcal/kg/day.
For pediatric patients age 3 or older, the Galveston formula is most often used:
1800 kcal/m2 + 2200 kcal/m2 of burn
For pediatric patients age 3 or younger, a formula devised by Mayes and colleagues is often
used:
108 + (68 x kg weight) + 3.9 % TBSA burn (children generally calculated to need 40+
kcal/kg/day)
It is recommended that burn patients receive no more than 7 mg carbohydrate/kg/minute,
because the excess is converted to fat, leading to an increase in consumption of oxygen and
production of carbon dioxide, which can cause respiratory difficulty. Too much carbohydrate also
can cause to hyperglycemia, diuresis, and dehydration. Too much lipid will likely lead to
impaired immune system functioning and a resultant increased risk of infection. However,
omega-3 fatty acids might combat this risk to immune function. In fact, omega-3 fatty acids may
positively modulate the inflammatory and immunological response. It is reasonable to provide
12%-15% of nonprotein calories from lipid. If attention is given to immune function, tolerance to
feeding, and triglyceride levels, it is possible to gradually increase the amount of fat provided. It
is hypothesized that medium-chain triglycerides (MCT) are oxidized better than triglycerides,
and that use of structured lipids improves protein synthesis in the liver, while reducing
catabolism of protein and expenditure of calories. In any case, fat should not exceed 2 g/kg/day.
Protein should provide 20%-25% of total calories, preferably protein of high biologic value.
Generally, adults will need 1.5-2 g protein/kg/day, and children will need 2.5-3.0 g
protein/kg/day.
Arginine may help increase immune functioning and wound healing. It appears that arginine
helps wound healing by aiding collagen deposition into wounds and by causing an increase in
nitrogen retention. However, studies have shown mixed results when testing the safety of
arginine supplementation on patients with sepsis, because arginine seems to increase nitric oxide
production.
Glutamine becomes a conditionally essential amino acid following trauma and may help to
prevent bacterial infection, improve overall immune function, decrease protein breakdown,
increase nitrogen retention and muscle mass, stimulate release of growth hormone, help to
preserve gut integrity, and act as an antioxidant. In one study, plasma glutamine levels of patients
decreased by 58% and levels remained depressed for at least 21 days following a severe burn.
Most vitamins are provided in excess of the DRI in standard tube feedings and TPN
prescriptions, because of the high amount of feeding necessary to sustain burn patients.
However, needs for most vitamins are increased five to ten times in burn patients. Additional
vitamin C and vitamin A often are recommended for wound healing and collagen synthesis.

Patients sometimes present with hyponatremia following a traumatic injury, with correction
occurring with the restriction of free water and other sodium-free beverages. Hypokalemia more
often appears during the protein synthesis phase of recovery. Patients with severe burns often
will present with hypocalcemia and concurrent hypoalbuminemia. Calcium supplementation is
recommended if the patient is symptomatic. Supplemental phosphorous and magnesium also are
frequently called for and are often given via TPN to prevent gastrointestinal upset. Zinc
supplementation of 220 mg zinc sulfate often is recommended for burn patients. Some burn
centers also use supplemental manganese and copper for connective tissue and ground substance
synthesis.
Patients with less than a 20% TBSA burn often can receive oral feeding, with a high-calorie and
high-protein, diet. Tube feeding always is preferential to TPN for more severely injured patients,
although TPN is frequently medically necessary if persistent ileum with nontolerance of tube
feeding or a high risk of aspiration is present, or if skin grafting or other medical procedures will
cause an interruption in enteral feeding. Commercially available general-use oral supplements
often contain a high level of simple sugars and a protein content that is too low for burn patients.
Use of specialized formulas, if available, is recommended.

Evaluating the effectiveness of nutritional care

A 24-hour nitrogen balance study is recommended, whenever possible. Net nitrogen loss should
not exceed 5 g/day. To evaluate the meeting of nutritional needs, it is useful to look at albumin
and prealbumin levels, weight maintenance, and status of wound healing. Because patients will
frequently retain fluid during the healing process, it is importance to note the presence of edema
or other signs of fluid retention. Liver enzyme panels are useful for monitoring cholestasis. It
also is important to test blood glucose levels frequently. Triglyceride levels are useful for
monitoring tolerance to tube feeding and TPN prescriptions, and should not exceed 250 mg/dL.

References
De-Souza DA, Greene LJ. Pharmacological nutrition after burn injury. J Nutr. 1998;128:797-803.
Winkler MF, Ainsley MM. Medical nutrition therapy for metabolic stress: sepsis, trauma, burns,
and surgery. In: Mahan LK, Escott-Stump S, eds. Krauses Food, Nutrition, and Diet Therapy.
11th ed. Philadelphia, PA: WB Saunders; 2004:1059-1076.
Burn Survivor Resource Center. Medical care guide: nutrition. Available at:
http://www.burnsurvivor.com/nutrition.html. Accessed November 29, 2007.
Demling RH, DeSanti L, Orgill DP. The burn nutrition module. Available at:
http://www.burnsurgery.org/Betaweb/Modules/burnnutrition/sec1.htm.
Accessed November 29, 2007.
Review Date 2/08
G-0525