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Medical Nutrition Therapy: Burn Patients

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.

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Medical Nutrition Therapy: Burn Patients

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  1. Medical Nutrition Therapy: Burn Patients Amy Gabrielson

  2. 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.

  3. 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.

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

  5. Burn exposure cont… • Electrical Exposure • An electrical current moves through the tissue • Severity correlates with voltage, location of contact and amount of time exposed Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education.

  6. “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.html 2Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education.

  7. 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. 62:2015-26 Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education.

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

  9. 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. Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education. Monstrey, S, Hoeksema, H, Verbelen, J, Pirayesh, A, Blondeel, P. (2008). Assessment of burn depth and wound healing potential. Burns. 34:761-769.

  10. 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.

  11. 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.

  12. Goal of Medial Treatment • Prevent tissue necrosis • Maintain global tissue perfusion • Prevent infection • Reduce scarring

  13. Medical Treatment • Topical Agent- Prevents Infection • Silver Sulfadiazine cream, Silver Nitrate • Clean wound dressings • Some wounds require skin grafting • Requires multiple surgeries Nelms, Sucher, Long. (2007). Burns. Nutrition Therapy and Pathophysiology. Belmont (CA): Thomson Higher Education.

  14. Nutrition Therapy Goals • Promote wound healing • Maintain lean body mass • Restore fluid levels

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

  16. 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.

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

  18. 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.

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

  20. Table 1: Nutrition Support for Burn Injuries Table 1 Use of the modified Harris-Benedict equations to estimate resting energy expenditure Men: 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. Chang D. Michael, Peck Yih. (1999). Nutrition Support for Burn Injuries. J Nutr Biochem. 10:380-396.

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

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

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

  24. 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

  25. 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.

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

  27. Vitamin C • Needed for edema prevention • Involved in collagen synthesis for wound healing • Aid in immune functioning Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition. 25:261-269.

  28. Vitamin A • Needed for immune function • Epithelialization • 5000 IU of Vitamin A per 1000 cal of enteral feeding is recommended Chan, M.M., Chan, G.M. (2009). Nutrition therapy for burns in children and adults. Nutrition. 25:261-269.

  29. 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.

  30. 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.

  31. 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

  32. 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

  33. Questions? Thank you 

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