Medical

Nutrition
Therapy for
burned patients

dr Rania Hussein
Definition of a Burn

Tissue injury caused by thermal,

radiation, chemical, or electrical
contact resulting in protein
denaturation, burn wound edema, and
loss of intravascular fluid volume due
to increased vascular permeability.

Beers, Mark H. M.D. 2003 The Merck Manual of Medical Information (2nd ed.). New Jersey; Merck Research
Laboratories.

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Causes of burns

1. Thermal burns
2. Radiation burns
3. Chemical burns
4. Electric burns

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Tissue layers

Epidermis
Dermis

Subcutaneous
tissue

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First-degree burns

The epidermis is affected

Red, sensitive, and moist
Slight swelling is present
+ painful
No scarring

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Second-degree burns
The Dermis is affected
May produce blisters + painful
May blanch with pressure

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Third-degree burns= full-
thickness burns
Subcutaneous tissue is affected
Skin is destroyed

Muscle tissues and bone may be damaged

Burned area is insensitive due to destruction of

nerve endings
Surface may be white; black charred; or bright red.

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Types of Pediatric Burns:
Scalds are the most
common type
A childs skin burns 4 times
more quickly and deeply
than an adults skin at the
same temperature.

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Burn Scoring

Burn scoring measures the percentage of the body

burned.

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Wallaces rule of 9

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Rule of Nines
Used to determine the percentage of TBSA affected in
patients >12 years old.

Head and neck 9%

Chest and Abd 18%
Back 18%
Arm 9% (each)
Leg 18% (each)
Hand 1% (each)
Genitalia 1%
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Burn size

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Fatal burn injuries
As a rule of thumb:
When % BSA+ age = > 100
unlikely to survive
Note: this equation is for > 10 y of age
Ex:

86 y old+ 30 % BSA burn=116 (survival unlikely)

13 y old+ 55 % BSA burn=68 (survival likely)

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Assessment of Burns

3 important criteria:
Burn Depth
Total Body Surface Area Burned (TBSA)
Involvement of anatomically sensitive areas
(Face, Hands and Feet, Genitalia, Major Joints).

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Classification of Burn
Injury

Minor burns
First- or second-degree burn covering
< 15% of an adults body , or
< 10% of a childs body, or
Third-degree burn on < 2% BSA.

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Moderate burns
First-or second-degree burns covering :
15%-25% of an adults body, or
10%-20% of a childs body, or

Third-degree burn on 2%-10% BSA.

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Major burn= shock burn:
First-or second-degree burns covering
> 25% of an adults body or
> 20% of a childs body, or

Third-degree burn on more than 10% BSA.

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Hypermetabolic Response
Ebb Phase: Flow Phase:
Decreased Increased
Cardiac output Cardiac Output
O2 consumption O2 consumption
Body temperature Body temperature
Protein catabolism

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Causes of
Hypermetabolism
Elevated levels of inflammatory mediators
Hormonal mediators (cortisol, glucagon, and
catecholamines)
Escape of bacteria or endotoxin from wound or
intestine

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Burns >10% TBSA: Possible
complications:
I. Hypovolemia respiratory injury
II. Bacterial invasion and sepsis
III. SIRS MODS
IV. Curlings Ulcer

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The Burn Team involves many
health care professionals:

1. Plastic Surgeon
2. Pediatrician
3. Nurse
4. Physiotherapist
5. Nutritionist
6. Social Worker or Psychologist

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Initial Assessment: Patient should
be assessed within 24 hours of hospital
administration
1. Preadmission or preoperative nutrition status
2. Diagnosis: organ function, injury type, extent
3. Ability to predict clinical course: ex length of
intubation
4. GI function, (and ability to predict return of its
function if impaired)
5. Need for enteral or parenteral nutrition
6. Nutrition support access options
7. Height, premorbid weight
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Nutritional Support

Minor burn :
No need of IV fluid rescuscitation
REE mildly
Maintain on a high energy, high protein diet,
Challenges: Sedation, fear, pain, foul smelling
dressings, can affect oral intake

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Nutritional Support

Moderate to Major Burns: Enteral nutrition :

Enteral nutrition should begin as soon as
possible 8 - 48 hours after burn occurs

If delayed gastric emptying aspiration and

nausea ND and NJ feedings preferred

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Nutritional Support

Moderate to Major Burns:

PN can supplement enteral nutrition if
caloric requirements cannot be met
TPN is Undesirable due to septicemia,
difficult venous access only used in
Prolonged paralytic ileus

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Fluid Resuscitation

Fluid losses in burn is due to:

UOP, diarrhea, vomiting,
Evaporative loss: (due to lack of water
impermeable layer of skin)

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Fluid Resuscitation
1st 24- 48 hrs are devoted to fluid and electrolyte
replacement

Adults:
Parkland Formula
% TBSA burned x weight in kg x 4cc = 24h total fluid
needed
1/2 over the first 8 hours
1/2 over the next 16 hours

Caution: Overhydration can cause pulmonary edema

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Once resuscitation is complete, ample
fluids must be given to cover both
MAINTENANCE + EVAPORATIVE LOSS

fluid needed/d to compensate for

EVAPORATIVE LOSS =
% TBSA burned x weight in kg x 2 cc
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Fluid Resuscitation

Via short peripheral IV line in the unburned skin

Monitor :
1. CVP
2. urine output at least 1cc/kg/hr
3. S Na
4. Weight evaluation is difficult because of fluid
shifts and edema

Literature evidence does not support colloid use

during resuscitation
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Energy

Care should be taken not to

overfeed the patients (why)

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Energy requirement

Curreri formula:
24kcal/kg UBW/day + (40kcal x %TBSA
Burned (using a maximum of 50% burn))

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Harris-Benedict Equation as
REE
REE by Harris-Benedict Equation
Females:
655 + (9.56 x W) + (1.85 x H) - (4.68 x A)
Males:
66.5 + (13.75 x W) + (5 x H) - (6.78 x A)
Adjust for activity, stress (1.6), thermal
factor
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Carbohydrate

Should provide approximately 50- 60%

total calories
Maximum rate of 5mg/kg body
weight/minute (otherwise fat synthesis)
Excessive carbohydrate feeding is
hazardous (why?)

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In case of hyperglycemia:
1. Treat underlying sepsis if present

2. Give insulin, and DO NOT RESTRICT

G INTAKE
3. Recheck for over estimation of nutrient
requirements

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Protein

Should provide 20% of energy requirement= Up

to 2 g/kg body weight/day,

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 Nitrogen Excretion; max cat 10
d post burn, anabolism starts 20 -30 d post burn
Major Burn
40 Major Trauma

Major Operation
Nitrogen Excretion

30
(g/day)

20

10

0
10 20 30 40 50 60 70

Days
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Fat
Limiting lipid to 12%-15% non protein calories
is suggested
Studies showed that feeding only 15% of the
calories as fat to burned patients reduces
infectious morbidity and shortens length of
stay (excess fats weakens the immune
system).

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Comparing Omega 6 and
Omega 3 fatty acids

Omega 6 (50%)
Amplified stress response
Omega 3 (50 %)
Reduced stress response

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MCT are preferred as :
LCT must be emulsified by bile salts to form
micelles hydrolyzed by pancreatic lipase in SI
absorption
MCT are absorbed directly by enterocytes
portal system liver. (SO MCT absorbed despite severe
deficiencies in pancreatic function less steatorrhea).
MCT (unlike LCFA) do not require
carnitine for their entry to mitochondria
and oxidation
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intralipid may not be indicated in 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
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 signs of essential fatty acid deficiency are likely obscured
during burn injury
Because they may interfere with platelet function, are
associated with poor immune function, a small amount of
IV lipids are given if enteral nutrition cannot be started by
week 3 of admission.
This however is rarely necessary, particularly since:
1. many patients advance to full enteral support by then.
2. Patients may also receive essential fatty acids during
propofol infusions.

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Vitamins, minerals, and
trace elements
The Burns Interest Group recommended that:
with the possible exception of vitamin C and
trace elements, additional supplementation is
unnecessary , also they may result in competition
for absorption: eg: between Cu and Zn

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Vitamin C

Involved in collagen synthesis and

immune function
g /12h

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Iron
Iron supplements should be avoided in
protein depleted patients as:
Unbound iron bacterial overgrowth

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But what about burned children?

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Energy requirement in burned children?

Because normal children have a high activity

level, weight maintenance in burned children can
be achieved by:

EAR of a burned child confined to bed

= EAR of a non- burned active child

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Protein requirement in burned
children?
Children recovering form burn require higher
protein intake .
The Burns interest Group recommends the
following as a guide:
Infants<1 y use RNI for protein
1-3 y 2-3 g protein/Kg
>3 y 1.5- 2.5 g protein/Kg

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Post Burn Nutrition Monitoring and
evaluation

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 Parameter Frequency

24 h urine collection Daily

UUN
Maximum body temp Daily

I//O Daily

Stool output and consistency daily

Body weight On admission, then when

dressings changed

Bd glucose 4 hourly in the first 24 h,

then as indicated
Indirect calorimetry Several times /week
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 Parameter Frequency

Bd urea Daily during 1st week then

Twice weekly
S electrolytes Daily during 1st week then
Twice weekly
CBC Twice weekly

Liver function tests Twice weekly

CRP Twice weekly

Trace elements weekly

UUN weekly

S albumin, prealbumin, weekly

transferrin dr Rania Hussein
For proteins consider:

1. N2 balance
2. Negative and positive phase
respondents

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Nitrogen Balance: imp
Used to evaluate the efficiency of a nutritional regimen

Nitrogen Balance =
Nitrogen intake [24-hour UUN + fecal nitrogen loss
( 2g/24 hour) + wound nitrogen loss (g/24hour)]

Calculating wound nitrogen loss:

<10% open wound = 0.02 g nitrogen/kg/day

11%-30% open wound = 0.05 g nitrogen/kg/day
>31% open wound = 0.1 g nitrogen/kg/day
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Finally, How to follow the
magnitude of the catabolic
stress?

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PP in monitoring protein:
limitations
1. S albumin, transferrin, and prealbumin
quickly post burn,
2. Still these PP due to undernutrition

So, CRP is used to interpret their levels.

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CRP is an acute phase reactant:
1. within 4- 6 hrs after stress

2. when CRP begins to pt has entered

anabolic phase

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 So if PP

Normal or low CRP High CRP

Malnutrition Acute phase

response
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1. So at entry to anabolic phase S
prealbumin (t = 2 d) begins to at
almost the same time that CRP begins to

Usually S albumin levels remain

depressed until major burns are healed.

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2. Catabolic index indicates change from stressed to non
stressed (provided that renal function is normal)
To estimate Catabolic index , estimate 24 h UUN/d

If
<5 g = no stress
5- 10 g = level I stress= mild hypermetabolism
10- 15 g = level II stress= moderate hypermetabolism
> 15 g = Level III stress= severe hypermetabolism

dr Rania Hussein