MEDICAL NUTRITION THERAPY: BURN PATIENTS Amy Gabrielson

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Medical Nutrition Therapy Burn Patients

• Amy Gabrielson

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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.

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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.
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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.
622015-26
Nelms, Sucher, Long. (2007). Burns. Nutrition
Therapy and Pathophysiology. Belmont (CA)
Thomson Higher Education.
8
Medline Plus (2009) www.nlm.nih.gov/.../ency/fulls
ize/1078.jpg
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Rule of 9s

• 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. 34761-769.
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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. 34761-769.
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.
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Goal of Medial Treatment

• Prevent tissue necrosis
• Maintain global tissue perfusion
• Prevent infection
• Reduce scarring

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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

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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.
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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.
25261-269.
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.
25261-269. Chang D. Michael, Peck Yih.
(1999). Nutrition Support for Burn Injuries. J
Nutr Biochem. 10380-396. Potts, N.L.,
Mandleco, B.L. (2007). Pediatric Nursing Second
Edition. New York Thomson Delmer Learning. .
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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.
10380-396.
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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.
10380-396.
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Table 1 Nutrition Support for Burn Injuries
Table 1 Use of the modified Harris-Benedict
equations to estimate resting energy
expenditure Men BEE(66.4713.75W5.0H-6.76A)x(Ac
tivity Factor)x(Injury and/or Burn Factor) Women
BEE(655.119.56W1.85H-4.68A)x(Activity
Factor) x(Injury and/or Burn Factor) Wweight
in kg Hheight in cm Aage in years.
Chang D. Michael, Peck Yih. (1999). Nutrition
Support for Burn Injuries. J Nutr Biochem.
10380-396.
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.
10380-396.
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.
10380-396.
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.
10380-396.
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.
25261-269. 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 19482-91
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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.
25261-269. Chang D. Michael, Peck Yih. (1999).
Nutrition Support for Burn Injuries. J Nutr
Biochem. 10380-396.
26
Assessing Nutritional Status

• Pre-Albumin and Albumin for protein status
• Pre-Albumin 15 mg show malnutrition
• lt10mg/dl- Deficient
• Albumin lt3.0mg/dl- Deficient
• Weight loss of 5 in 30 daysMalnutrition

Chan, M.M., Chan, G.M. (2009). Nutrition therapy
for burns in children and adults. Nutrition.
25261-269.
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.
25261-269.
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.
25261-269.
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.
25261-269.
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.
25261-269.
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

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Summary

• Burns result from thermal, chemical and
  electrical sources
• Burns are classified as Superficial, Partial
  thickness and Full-thickness
• Rule of 9s for BSA
• Burns cause a inflammatory, stress response
  affecting many bodily systems
• Protein is essential for wound healing
• Vitamins and Minerals supplements are neccesary

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Questions?

• Thank you ?