MEDICAL NUTRITION THERAPY: BURN PATIENTS Amy Gabrielson

MEDICAL NUTRITION THERAPY: BURN PATIENTS

Amy Gabrielson

Objectives

Be able to classify different types of burns and their severity.

Be able to understand how burns affect the body.

Identify the medical treatments for burn patients.

Identify the medical nutrition therapy for burn patients and its importance to the patient.

Be able to understand the ethical issues that accompany burn victims.

Causes of Burns

Burns result from physical exposure to: heat, chemicals, radiation or electricity

Injury affects the skin and in some cases muscle and bone. Severity of the burns is classified by how

deep the burn penetrates the body.

Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education.

Burn Exposure Thermal Exposure- Direct contact with a

heat source i.e. hot water, flames Most common and commonly occur in the home or workplace

Chemical Exposure Coming into contact with chemicals that

cause a reaction on the body.


Burn exposure cont…

Electrical Exposure An electrical current moves through the

tissue Severity correlates with voltage, location of

contact and amount of time exposed


“Medical treatment is required for more than1.1 million burn victims each year with approximately 45,000 hospitalizations.” 1

“Mortality rate from burns has declined significantly over the previous several decades due to major advances in medical care.”2

1 National Institute of General Medical Sciences. Trauma, Shock, Burn and Injury: Facts and Figures. Bethesda (MD): National Institute of General Medical Sciences, National Institute of Health. Available from: http://publications.nigms.nih.gov/factsheets/trauma_burn_facts.html2Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education.

Burn Classifications

Superficial (First Degree) Top layer of epidermis- sunburn

Partial Thickness (Second Degree) Destruction of the epidermis and dermis

Full Thickness (Third & Fourth Degree) Destroys all layers of skin and can involve

underlying muscle, organs and bones.

Morgan ED, Bledsoe SC, Barker J. (2000). Ambulatory management of burns. Am Fam Phys. 62:2015-26Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education.

Medline Plus (2009) www.nlm.nih.gov/.../ency/fullsize/1078.jpg

Rule of 9’s

Makes estimation of body surface area (BSA) affected by burns.

Helps assess the extent of the burn and helps provide basis for prescribing fluid and medication.


Monstrey, S, Hoeksema, H, Verbelen, J, Pirayesh, A, Blondeel, P. (2008). Assessment of burn depth and wound healing potential. Burns. 34:761-769.

Assessment of Burn Depth

Burn depth needs to assessed to determine treatment goals and actions.

Surgeons need to know burn depth to assess potential for scarring.

Thermal imaging, Vital Dyes and Laser Doppler imaging

Monstrey, S, Hoeksema, H, Verbelen, J, Pirayesh, A, Blondeel, P. (2008). Assessment of burn depth and wound healing potential. Burns. 34:761-769.

Effects of Burn on the Body

Extensive inflammatory response Rapid fluid shifts and accumulation. Hypermetabolic state Muscle protein catabolism Decrease cardiac output because of increased

capillary permeability and vasodilation. Heat loss Increased blood glucose levels Burn Shock

Potts, N.L., Mandleco, B.L. (2007). Pediatric Nursing: Second Edition. New York: Thomson Delmer Learning.

Goal of Medial Treatment

Prevent tissue necrosis Maintain global tissue perfusion Prevent infection Reduce scarring

Medical Treatment

Topical Agent- Prevents Infection Silver Sulfadiazine cream, Silver Nitrate

Clean wound dressings Some wounds require skin grafting

Requires multiple surgeries


Nutrition Therapy Goals

Promote wound healing Maintain lean body mass Restore fluid levels

Fluid Therapy

Need for fluid resuscitation to maintain global tissue perfusion.

Parkland Formula is used to calculate the amount of fluid to use to resuscitate the patient based on burn percentage. 4mL/kg/% burn in the first 24 hrs, half of

which is given in the first 8 hours Be careful not to over resuscitate in fear or

burn edema. Vitamin C and Vasopressin help reduce fluid

requirementsTricklebank, S. (2009). Modern trends in fluid therapy for burns. Burns. 35: 757-767.

Hypermetabolism

Catecholamines, cortisol, and other glucocorticoids are increased in burn victims due to the stress state of the body causing a hypermetobolic response.

Epinephrine and norepinephrine increase 10-fold in people with burns greater that 30-40%.

Hypermetabolic state lasts 9-12 months after a burn.

Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition. 25:261-269.

Glucose Metabolism

Accelerated gluconeogenesis, glucose oxidation and plasma clearance of glucose

Blood glucose levels increase due to insulin resistance and breakdown of glycogen stores

Glucagon excretion by the liver increases initially after the burn and slows down as wound heals


Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:380-396. Potts, N.L., Mandleco, B.L. (2007). Pediatric Nursing: Second Edition. New York: Thomson Delmer

Learning..

Muscle Protein Catabolism

Protein catabolism increases in burn patients leading to protein losses of 260 mg protein/kg/hr.

Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:380-396.

Nutrition Therapy

Always prefer oral intake if possible Preserves GI function Food has therapeutic qualities that tube

feedings do not If a patient cannot consume 80% of

estimated caloric or protein needs, enteral feeding is needed

TPN may be contraindicative because of infection but should be used if necessary


Table 1: Nutrition Support for Burn Injuries

Stressors Stress Factors

Activity factor

Confined to bed

1.2

Out of bed 1.3

Injury factor

Minor operation

1.2

Skeletal trauma

1.3

Major surgery

1.4

Sepsis 1.6

Burn factor Stress Factors

20% TBSA 1.2

20–25% TBSA 1.6

25–30%TBSA 1.7

30–35% TBSA 1.8

35–40% TBSA 1.9

40% TBSA 2.0

Table 1 Use of the modified Harris-Benedict equations to estimateresting energy expenditureMen: BEE=(66.47+13.75W+5.0H-6.76A)x(Activity Factor)x(Injury and/or Burn Factor)Women: BEE=(655.1+19.56W+1.85H-4.68A)x(Activity Factor)x(Injury and/or Burn Factor)

W=weight in kg; H=height in cm; A=age in years.


Protein Requirements

Amino acids are important for collagen synthesis for wound healing

Maintaining visceral protein is important for organ function especially for immune systems Maintaining intercostal muscles and the

diaphragm is imperative for respiratory efficiency 1.4-2.2 g/kg protein requirement for burns Urinary nitrogen losses increase with severity of the

burn injury Trauma patient may lose 20-25 g of lean body

nitrogen dailyChang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:380-396.

Protein Requirement cont…

Protein requirement estimate: Combine 24-hour urinary nitrogen loss, 2 to 4 g

of nitrogen for fecal loss and 4 to 5 g/d for anabolism.

Convert each gram of nitrogen to 6.25 g of protein.

Patients are likely to miss feedings if in surgery frequently so should be given high protein formulas between surgeries Be aware of uremia- increase free water

Generally 20-25% of calories from proteinChang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:380-396.

Lipid requirements

Lipid stores are critical for long-term fuel after major thermal burns

Fat oxidation is higher in hypermetabolic patients than in normal patients

Fat consumption should not exceed 30% of the diet to avoid diarrhea

Beneficial because Fat is a more concentrated form of energy Vegetable oils contain essential fatty acids and

fat soluble vitamins Help with infection


Lipid Study

A randomized study of 43 adolescent and adult burned patients were administered a low-fat diet (15% total calories from fat) Administered enterally of parenterally

Less pneumonia, improved respiratory function, faster nutritional status and shorter length of care was found in comparison to a high fat diet of 35% of calories from fat

Recommended 12-15% of calories to be lipids

Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition. 25:261-269.Garrel D.R, Razi M, Lariviere F, Jobin N, Naman N, Emptoz-Bonneton A, et al. (1995) Improved clinical

status and length of care with low-fat nutrition support in burn patients. JPEN 19:482-91

Carbohydrate Requirements

Carbohydrate metabolism is significantly affected in burn patients Gluconeogenesis from Alanine and other AAs

are elevated Carbohydrates are good sources for protein

sparing especially for nitrogen retention High carbohydrates can contribute to

hyperglycemia in which case a diet can be altered to increase fat in the diet

Recommended 60% of the calories from CHO, not surpassing 400g/d or1600 kcal/d

Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition. 25:261-269. Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:380-396.

Assessing Nutritional Status

Pre-Albumin and Albumin for protein status Pre-Albumin 15 mg show malnutrition

<10mg/dl- Deficient Albumin <3.0mg/dl- Deficient

Weight loss of 5% in 30 days=Malnutrition


Vitamin C

Needed for edema prevention Involved in collagen synthesis for wound

healing Aid in immune functioning


Vitamin A

Needed for immune function Epithelialization 5000 IU of Vitamin A per 1000 cal of

enteral feeding is recommended


Vitamin D and Calcium

Burns cause an impairment in the metabolism of Vitamin D

Burn patients are more susceptible to fractures so calcium and vitamin D should be administered

Calcium- 1000 mg daily Vitamin D- 200-400 IU daily

Maintain serum 25-hydroxy vitamin D level of 30-60 ng/Ml

Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition.

25:261-269.

Zinc and Copper

Zinc and copper deficiencies have been seen in burn patients most likely from tissue breakdown and urinary excretion.

Supplementation is recommended for patients

Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition.

25:261-269.

Ethical Issues

The quality of care and the recovery of burn patients depend on the amount of effort the healthcare providers put into the patient.

Quality of life

Summary

Burns result from thermal, chemical and electrical sources

Burns are classified as Superficial, Partial thickness and Full-thickness

Rule of 9’s for BSA % Burns cause a inflammatory, stress

response affecting many bodily systems Protein is essential for wound healing Vitamins and Minerals supplements are

neccesary

Questions?

Thank you

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MEDICAL NUTRITION THERAPY: BURN PATIENTS Amy Gabrielson