Nutritional Needs of a burns patient by Jess Standing

2022-03-14 10:49:14 UTC

Protein requirements are significantly increased in burned patients. Protein is necessary for wound healing, enhancement of host defence mechanisms and replacement of losses.

2022-03-14 10:52:41 UTC

INTRAVENOUS (IV) MAINTENANCE FLUIDS

Additional IV maintenance fluids is only required if clinically indicated, if the child is not tolerating oral fluids or the child is <12months old:

For 1st 10kg = 4ml/kg/hr
For 2nd 10kg = 2ml/kg/hr
Every extra kg = 1ml/kg/hr

2022-03-14 10:52:54 UTC

Insertion of a nasogastric tube and commencement of enteral feeds should be considered for children who sustain significant burn injuries and/or facial burns and are unable to tolerate adequate oral intake. Where possible feeds should commence within 6 - 8 hours of the burn injury.

2022-03-14 10:53:11 UTC

* FEEDING/NUTRITION

Start oral/enteral feed as soon as possible (post operatively) and increase as quickly as tolerated to maximum fluid allowance and decrease crystalloid accordingly (refer to dietitian). Monitor aspirates.

2022-03-14 10:53:30 UTC

Children require 1,800 kilocalories per square meter of body surface plus 2,200 kilocalories per square meter of burn area per day to maintain body weight (NCBI, 2011)

2022-03-14 10:53:44 UTC

Children with significant burn injuries are at risk of acute gastric ulceration and a H2 antagonist should be considered for these patients.

2022-03-14 10:54:22 UTC

Hourly fluid balance. Urine outputs > 2mls per kg per hour for more than two hours should result in a decrease in resuscitation fluid. Urine outputs < 0.5ml/kg/hr should result in clinical examination and serum urea and electrolytes should be checked

Hildreth formula for energy requirements

2022-03-14 10:54:48 UTC

Children <12 1800kcal/m2 Total Body Surface Area (TBSA) + 1200kcal/m2 Burn Surface Area(BSA)

2022-03-14 10:55:55 UTC

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3255093/

2022-03-14 10:56:05 UTC

full feeding in the acute phases of critical illness does not provide an advantage over trophic feeding and may be harmful.

2022-03-14 10:56:24 UTC

Nutritional support is a critical aspect of the treatment of burn patients. The metabolic rate of these patients can be greater than twice the normal rate, and this response can last for more than a year after the injury.

2022-03-14 10:56:40 UTC

http://www.uhbristol.nhs.uk/for-clinicians/clinical-guidelines/

2022-03-14 10:56:59 UTC

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6998073/

2022-03-14 10:57:00 UTC

Appropriate wound healing is achievable in children over 1 year receiving 2-3g protein/day

2022-03-14 10:57:14 UTC

https://www.rch.org.au/rchcpg/hospital_clinical_guideline_index/Nursing_management_of_burn_injuries/

2022-03-14 10:57:43 UTC

https://jeccm.amegroups.com/article/view/4372/4984#:~:text=Protein%20need%20in%20burned%20children,lower%20than%2035%25%20of%20TEI.

2022-03-14 10:58:20 UTC

https://www.inmo.ie/article/printarticle/3431

2022-03-14 10:58:27 UTC

https://www.cobis.scot.nhs.uk/wp-content/uploads/2016/04/Paed-Guideline-COBIS-nutrition-2016.pdf

2022-03-14 10:58:51 UTC

Time to treatment, including time to nutrition, is an important factor for patient outcome after severe burn. Substantial intestinal mucosal damage and increased bacterial translocation occur after burn and result in decreased absorption of nutrients. Because of this, nutritional support should ideally be initiated within 24 h of injury via an enteral route.

2022-03-14 10:59:10 UTC

Nutritional requirements may be achieved by:

High protein, high calorie diet (including oral nutritional supplements)
High protein, high calorie diet with supplemental enteral feeding
Enteral feeding.

POINT 1

2022-03-14 10:59:11 UTC

It is important to eat a protein rich, high calorie diet throughout recovery because:
Support immune system
Help wound/s to heal
Maintain muscle mass and strength
Minimise weight loss
Support rehabilitation

Nutritional requirements decrease and approach pre-injury levels as wound healing progresses. Research indicates that increased protein intake during the recovery phase increases body weight gain and muscle function.

2022-03-14 10:59:40 UTC

Proper nutrition aids in recovery - nutrition given to the patient provides the body with more energy, meaning they are able to heal. In proper nutrition can cause harm to the recovering patient

2022-03-14 10:59:48 UTC

2022-03-14 11:01:22 UTC

High-carbohydrate, low-fat diets for burn patients result in less proteolysis and more improvement in lean body mass and may reduce infectious morbidity and shorten hospitalization time when compared with a high-fat regimen.

Advised PROTEIN RICH foods following burns injury (NHS North Bristol)

2022-03-14 11:02:01 UTC

High Protein Foods:
Meat, Fish, Eggs, Cheese, Milk

Vegetarian:
Beans, Nuts, Seeds, Soya

Drinks:
Milky drinks (hot chocolate/milkshakes), Milk

Snacks:
Custard, Rice pudding, Nuts, Yogurts, Cheese, Sausage rolls, Biscuits

2022-03-14 11:02:14 UTC

https://www.nbt.nhs.uk/sites/default/files/attachments/Eating%20well%20after%20a%20burn%20injury_NBT003132.pdf

2022-03-14 11:02:14 UTC

Failure to meet the increased substrate requirements may result in impaired wound healing, multi organ dysfunction, increased susceptibility to infection, and death.

2022-03-14 11:02:25 UTC

https://www.researchgate.net/publication/297604126_Nutrition_in_burn_patient

2022-03-14 11:02:41 UTC

Failure to adequately address the increased levels of inflammatory mediators, catecholamines, and corticosteroids central to the hypermetabolic response postburn injury can lead to catastrophic results

POINT 2- Vitamin D

2022-03-14 11:05:19 UTC

Main source of Vitamin D is from direct sunlight
If advised to stay out of sunlight it is important for patients to have a substantial intake of vitamin D to avoid a deficiency. Vitamin D supplements are often recommended- 10micrograms daily.

Reduced Appetit in burns patients

J3ss_S — 2022-03-14 11:06:03 UTC

Reasons can include:

being in hospital,
worrying,
restrictive dressings,
pain,
pain on dressing changes,
constipation,
dislike of hospital food,
feeling sick,
feeling weak
taste changes

2022-03-14 11:10:23 UTC

Enteral Nutrition:
- safe and cost effective feeding route
-has been found to have many advantages.
-The presence of nutrients within the lumen of the bowel promotes function of the intestinal cells, preserves mucosal architecture and function, stimulates blood supply, decreases bacterial translocation, and improves gut-associated immune function.
-EN decreases hyperglycemia and hyperosmolarity as it has a “first-pass” hepatic delivery of nutrients. For all of these reasons, EN is the route of choice for severely burned patients.

2022-03-14 11:12:57 UTC

Parenteral Nutrition
-PN was routinely used for burn patients in the 1960s and 1970s, but it has been almost completely replaced by EN
-PN, is associated with overfeeding, liver dysfunction, decreased immune response, and three-fold increased mortality
-PN has more mechanical and infectious complications of catheters, and PN solutions are significantly more expensive than EN formulas.
-Despite the strong preference to give nutritional support primarily via the gastrointestinal tract, PN can be used in burned patients in whom EN is contraindicated.

J3ss_S — 2022-03-14 11:24:09 UTC

Consider reduced appetite and be creative in increasing nutritional intake
Strict fluid balance required, input and output
Nutritional support should be started within the first 24 hours of the injury, but within 6-8 hours for optimum recovery

J3ss_S — 2022-03-14 11:30:03 UTC

Vitamin D supplements are important while avoiding sun exposure
Protein rich diet aids faster wound healing

Summary

2022-03-14 11:31:55 UTC

1. High carbs low fat diets result in less proteolysis and more improvement in lean body mass - failure to meet increased substrate requirements drastically impair healing.
2. Failure to meet the increased substrate requirements may result in impaired wound healing, multi organ dysfunction, increased susceptibility to infection, and death.

Key points

2022-03-14 12:46:46 UTC

If child not tolerating oral fluids or is < 12 months old, and it is clinically indicated then commence IV maintenance fluids as follows:

For 1st 10kg = 4ml/kg/hr
For 2nd 10kg = 2ml/kg/hr
Every extra kg = 1ml/kg/hr

- Enteral feeds must commence as soon as possible and increased to maximise fluid allowance and decrease crystalloid (water, electrolytes and glucose)

Key points

2022-03-14 12:54:59 UTC

Appropriate wound healing is achievable in children over 1 year receiving 2-3g protein/day

Children require 1,800 kilocalories per square meter of body surface plus 2,200 kilocalories per square meter of burn area per day to maintain body weight (NCBI, 2011)

Carbohydrates/ Protein

J3ss_S — 2022-03-14 13:01:48 UTC

- Carbohydrates are the favoured energy source for burn patients as high-carbohydrate diets promote wound healing and impart a protein-sparing effect.
A randomized study of 14 severely burned children found that those receiving a high-carbohydrate diet (in comparison to a high-fat diet) had significantly less muscle protein degradation

-This makes carbohydrates an extremely important part of the burn patient’s diet; however, there is a maximum rate at which glucose can be oxidized and used in severely burned patients (7 g/kg/day)

-The hormonal environment of stress and acute injury causes some level of insulin resistance, and many patients benefit from supplemental insulin to maintain satisfactory blood sugars. Insulin therapy also promotes muscle protein synthesis and wound healing

-Studies have found that severely burned patients who received insulin infusions, in conjunction with a high-carbohydrate, high-protein diet, have improved donor site healing, lean body mass, bone mineral density, and decreased length of stay

Protein:

-Protein supplementation is needed to meet ongoing demands and supply substrate for wound healing, immune function, and to minimize the loss of lean body mass.

- Protein is used as an energy source when calories are limited; however, the opposite is not true. Giving excess calories will not lead to increased protein synthesis or retention, but rather lead to overfeeding--
-Currently, protein requirements are estimated 2.5–4.0 g/kg/day for burned children

- Non-protein calorie to nitrogen ratio should be maintained between 150:1 for smaller burns and 100:1 for larger burns

- Even at these high rates of replacement, most burn patients will experience some loss of muscle protein due to the hormonal and proinflammatory response to burn injury.

·-Several amino acids are important and play unique roles in recovery after burn;

Glutamine directly provides fuel for lymphocytes and enterocytes and is essential for maintaining small bowel integrity and preserving gut-associated immune function. Glutamine also provides some level of cellular protection after stress, as it increases the production of heat shock proteins and it is a precursor of glutathione, a critical antioxidant. Glutamine has been found to reduce mortality and length of hospitalization in burn patients

The supplementation of arginine in burn patients has led to improvement in wound healing and immune responsiveness

https://burnstrauma.biomedcentral.com/articles/10.1186/s41038-017-0076-x