Nutritional concerns in critically ill burn patients

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70 Journal of Medical Nutrition and Nutraceuticals, Vol 4 / Issue 2 / Jul-Dec 2015
Nutritional concerns in critically ill burn patients
Sukhminder Jit Singh Bajwa, Gurpreet Kaur
Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India
Review Article
Introduction
Nutritional supplementation is an integral part of
therapeutic management in critically ill patients. The
challenges increased manifold if these patients are
admitted with co‑morbidities, trauma or any other
complication. Management of critically ill burn patients
is extremely challenging to the attending intensivist. The
gross pathophysiological changes, altered fluid dynamics,
vulnerability to infections, metabolic derangements,
electrolyte disturbances and severity of burns influence
largely the nutritional parameters and therapeutic
interventions. Ever since the evolution of critical care
services, attempts have been continuously made by the
researchers to improve and optimize the nutritional
status in critically ill‑patients. The evolving guidelines and
protocols of nutritional therapy in critically sick patients
can be extrapolated to burn patients also in Intensive
Care Unit (ICU), which has largely been supported by
the emergence of evidence‑based medicine. The current
manuscript is aimed at discussing important issues
pertaining to the nutritional supplementation of patients
admitted with varying degree of burns to the ICU.
Search Strategies
The present manuscript is an attempt to highlight the
understanding of the nutritional aspects in patient with
burns. The measures adopted included extensive scrutiny
of literary evidence from internet resources, journals
and textbooks of surgery, nutrition, anesthesiology and
intensive care. The strategies included exploration of
full‑text articles and abstracts from various search engines
such as PubMed, Medscape, Scopus, Science Direct,
Medline, Yahoo, Google Scholar and many others, which
included keywords such as enteral nutrition, burns,
intensive care, critically ill‑patients.
Current Recommendations and
Guidelines!
At present, various guidelines set up by European Society
for Clinical Nutrition and Metabolism are typically followed
in the ICU. ALLIANCE is one of the international
organizations, which is working at international as well
as at Indian level to set up the nutritional goals. Scope
of enteral nutrition has improved with the endoscopic
placement of jejunostomy and gastrostomy feeding tubes.
Development of various new bio‑markers of illness can also
be of great help in guiding the nutritional goals. Research
ABSTRACT
Nutritional issues in critical care are very important for the better prognosis of patients. These concerns are further heightened if critically
ill patients are admitted with co‑morbidities and deranged physiology. A similar scenario is encountered when patients with burns are
admitted in Intensive Care Units (ICU) for one indication or the other. Their short and long‑term prognosis mainly depends on prevention
of infection and maintenance of optimal nutritional status. The aim of the current manuscript is to review some of the challenging aspects
in critically ill‑patients admitted in ICU with history of burns.
Key words: Burns, critically ill‑patients, enteral nutrition, intensive care
Corresponding Author: Dr. Sukhminder Jit Singh Bajwa, House No. 27‑A, Ratan Nagar, Tripuri, Patiala, Punjab, India.
E‑mail: sukhminder_bajwa2001@yahoo.com
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in the field of pharmaco‑genomics has also linked the role
of nutrition in gene expression.[1]
Besides aggressive fluid management in burn patients,
nutritional supplementation is gaining enhanced clinical
significance. Such patients present with numerous clinical
challenges which have to be identified at the earliest so as
to achieve clinical stability. Management of these patients
needs a multidisciplinary approach. The inhalational
injury can lead to airway edema, fluid‑electrolyte
balance, thermoregulatory aspects and risk of infectious
complications. Inadequate nutrition in critically ill patients
impairs ventilatory drive and weakness of respiratory
muscles, thus increasing hospital stay. Nutrition supplies
important cell substrates and vital nutrients. Severe form
of burn injury is associated with the hypermetabolic
state. Various nutrients and many other agents have been
found to have their impact on the reversal of the this
hypermetabolic state.[2] This hyperdynamic circulatory
state is seen if burns are more than 40% of total body
surface area (TBSA) and leads to massive protein and lipid
breakdown resulting in muscle wasting. Hyperglycemia
occurs due to peripheral insulin resistance. Increase in
the levels of various hormones such as catecholamines,
glucocorticoids, glucagon and dopamine is responsible
for this catabolic state.[3] This altered metabolic state starts
within days of burn injury and may persist for several
years after burns.[4] Morbidity and mortality increases to
a significant extent as severe burn injury can affect each
and every organ of the body.[5] This increased mortality can
be reduced significantly with the use of high protein diet
along with early excision and grafting of burn wounds.[6] It
has been concluded from previous studies that early and
aggressive enteral feeding can improve the outcome by
normalizing the intestinal blood flow and by modulating
the hypermetabolic response. Enteral nutrition is preferred
over parenteral nutrition as the former one reduces
bacterial translocation, also maintains the motility of
intestine and thus increases the absorption of nutrients.[7]
Parenteral nutrition is usually reserved for those patients
who cannot tolerate enteral feed or have ileus. Postburn
ileus mainly affects stomach and colon and spares small
intestine. Thus in burn patients, early enteral feed within
6 h can be started via duodenal or jejunal routes.[8,9]
Nutrition plan of the burn patients should include site,
type and percentage of burns, age of the patient and any
other preexisting medical disorders. These factors are
important as patients having burns more than 10% of
TBSA along with burns of the face, genitalia, etc., need
special care. Children with burns more than 10% of TBSA
and patients with inhalational or electrical burns need to
be managed very carefully. Preexisting medical disorders
can enhance the mortality.[10]
Nutritional Requirements
Energy requirement in the acute phase can be calculated
from resting energy expenditures (REE). However,
increase is variable over time and mainly takes TBSA
into consideration. The concept of hyperalimentation
was followed earlier, but REE increase is seen during the
1st week, and it decreases thereafter. It has also been seen
that if the feed is given according to 25–30 kcal/kg/day,
chances of under feeding are more.[11,12] Overfeeding also
increases morbidity. The aim of nutritional support should
be to maintain the lean body mass as hypermetabolic state
results in catabolism in severe burns. Indirect calorimetry
is now considered as the gold standard to calculate energy
requirements in burn patients. Measurements are made in
the fed state, and the results of the analysis are rounded
to the upper 100 value, without exceeding + 10% of the
measured value. Carbohydrates form the major source of
energy as these provide glucose for metabolic pathways,
spare amino acids and also serve as fuel for wound healing
but should not be more than 60% of total energy intake
and should not be more than 5 mg/kg/min that is,
7 g/kg/day.[13] Fat should not be more than 30–35% of
nonprotein calories because the hypermetabolic response
in these patients suppresses lipolysis and limit their
breakdown to be used as source of energy.[14] Use of
low‑fat diet is advisable in severe burns. Use of omega‑3
fatty acids has been seen to be associated with improved
outcome as compared to the use of omega‑6 fatty acids as
metabolism of the former is associated without invoking
any inflammatory response.[15,16] Protein catabolism is also
common in burn patients, which can decrease lean body
mass and patients get more prone to infections. Burn
patients need 1.5–2 g/kg/day of the proteins in feed.[17‑19]
Formulas to calculate resting metabolic expenditure (RME)
are as follows:[20]
Mathematical formula to estimate RME:
Males = (66.5) + (13.7 × W) + (5 × H) − (6.8 × A).
Females = (655.1) + (9.6 × W) + (1.8 × H) − (4.7 × A).
W: Weight (kg)
H: Height (cm)
A: Age (years)
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Bajwa and Kaur: Nutrition in burn patients
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Above mentioned formula is for healthy, febrile individuals.
In patients with burns more than 30%, RME increases
by 100%.
Carbohydrates should provide 30–70% of total calories
needed. Fats should provide 20–50% and proteins
approximately 15–20% of total energy requirement.[21]
Formula to calculate REE is:
REE (Kcal) = −4343+ (10.5 × TBSA burned) + (0.23 × Kcal)
+ (0.84 × Harris Benedict) + (114 × T°C) − (4.5 × days
postburn).
Kcals = calories intake in past 24 h.
Harris Benedict = basal requirement in calories using
the Harris Benedict equation with no stress factors or
activity factors.
T = body temperature in degrees celsius.
Days postburn = the number of days after the burn injury
is sustained using the day itself as day zero.
Role of Glutamine
Glutamine acts as a main energy source for enterocytes
and lymphocytes. It is one of the important transport
amino acid. It performs various functions asit acts as a
source of energy for hepatocytes, maintains integrity,
permeability and immune function of small intestine
and improves wound healing.[11,12] The dose of glutamine
supplementation is around 0.3 g/kg/day.[13]
Role of Visceral Proteins in Critically
Ill Patients
Visceral proteins include albumin, transferrin, transthyretin
and retinol‑binding proteins. These proteins are mostly
synthesized in the liver. Inflammation and impaired liver
functions result in low blood levels of visceral proteins.
Hypoalbuminemia occurs in critically ill patients due
to “capillary leak syndrome” with albumin escaping
through more permeable capillaries into the interstitium.
Distribution of albumin gets affected with an infusion
of various fluids used for volume resuscitation of sick
patients. Hence, albumin cannot be used for assessment
and monitoring of the nutritional status.[21] In one of the
studies in the literature, relationship between visceral
proteins and clinical outcome has been assessed in 107
burned patients with biweekly measurements from day
12 to day 43 postburn. It has been observed that levels
of albumin and transthyretin increase more consistently
and rapidly in patients with burns <50% of BSA, whereas
further decline was reported for those who died between
day 20 and day 43.[22] It has also been observed that
transthyretin levels <50 mg/dl or failure to increase of
40 mg/L/week are associated with poor prognosis.[23,24]
It has also been seen in previous several studies that
immunonutrition rich in nucleotides and (omega)‑3 fish oil
decreases the mortality rate along with decrease in recurrence
rate of bacteraemia in sick patients in intensive care.[25]
Other Important Nutritional Aspects
in Burn Patients
Burn patients need sedation and analgesia very frequently,
so these are at increased risk of constipation. Thus, their
diet should be rich in fibers. Early enteral feed via gastric
route is preferred in these patients as it is associated with
attenuation of the stress response, stress‑induced ulcers
and increased production of immunoglobulins. Few
factors can prevent early start of enteral feeding as in the
initial phase of resuscitation, larger amounts of crystalloids
used, can lead to edema of the intestine and paralytic
ileus. Enhanced capillary leak in the early phase of burns
increases the fluid requirement.[26]
Micronutrient supplementation reduces the mortality
and morbidity in critically ill patients as their deficiency
results in lowered host defenses and impaired production
of antioxidants. Also, the intravenous route is best for their
supplementation. Duration, dose and timing of giving
these micronutrients are the important considerations for
improving their utility.[27] Thus the addition of copper, zinc,
selenium, Vitamin B1, C, D, E to feed is of great helpful.
Copper, zinc and selenium are lost in larger amounts
in burn patients in the exudate. Their supplementation
decreases fat breakdown, improved wound healing,
and thus shorter hospital stay. Thiamine replacement
improves lactate and pyruvate metabolism. Vitamin C and
E supplementation enhance wound healing. Their dose
should be 1.5–3 times higher than recommended daily
intake. Loss of Vitamin D is also needed to prevent bone
loss. Increased oxidative stress in burn patients is associated
with enhanced depletion of micronutrients. Several
other measures like warm ambient temperature (28–30°
centigrade), nonselective beta blockers (propranolol) and
oxandrolone are also important measures, which prevent
hypermetabolism and hyper catabolism in burn patients.[13]
Beta blockers, by reducing heart rate by 20% attenuate
stress hormone release. Propranolol can be started at
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the end of the 1st week of burns.[28,29] Oxandrolone in a
dose of 10 mg/12 h decrease mortality and thus hospital
stay in burn patients.[30,31] There is no role of arginine
supplementation according to the recent review.[32]
Ornithine alpha‑ketoglutarate is precursor and thus an
alternative to glutamine, it’s use during acute phase after
burns improves nitrogen balance.[33]
Glucose Control in Burn Patients
Target glucose levels between 5 and 8 mmol/L has been
seen to be associated with several clinical benefits such
as better graft uptake, lesser infectious complications
and ultimately decreased mortality. 100–150 mg/dl is a
standard target, which is otherwise maintained in other
critical patients in ICU.[34,35] Exenatide, a new incretin,
which inhibits glucagon secretion can decrease external
insulin requirement in pediatric burn patients.[36]
Adequate pain control and physiotherapy are also essential
in early rehabilitation of these patients.[13]
Enteral Versus Parenteral Nutrition
The enteral nutrition maintains the integrity of intestine
by maintaining tight junctions between intraepithelial cells,
enhance intestinal blood flow and induce the release of
cholecystokinin, gastric, bombesin and bile salts. It also
maintains villous height and support IgA producing
immunocytes. Within hours of major insult, intestinal
permeability changes due to loss of functional integrity thus
increasing the risk and severity of infectious complications.[37,38]
Indications of enteral nutrition:[39,40]
Major reason for preference of enteral nutrition over
parenteral nutrition is decrease in morbidity with the use
of enteral nutrition due to reduction in the incidence of
central venous line‑related infections, pneumonia and
abdominal abscess in trauma patients.[41] In several studies,
benefits in the form of a decrease in hospital stay, cost of
nutrition and regain of the cognitive function in head
injury patients has been seen with enteral nutrition.[42,43]
Five of the various six meta‑analysis done in the literature
has shown no difference in the mortality between enteral
and parenteral form of nutritional therapies.[42,44‑47] In
a study done by Simpson and Doig, despite the higher
incidence of infectious complications with use of parenteral
nutrition, significantly lower mortality has been seen as
compared to enteral nutrition.[48]
Enteral feeding should be started early within first 24–48 h
after admission, once fluid resuscitation is complete
and patient is hemodynamically stable. Feed should be
advanced towards desired target within next 48–72 h. In
a study by Marik and Zaloga, a significant reduction in
infectious morbidity and hospital stay has been seen with
early enteral nutrition when compared to delayed start.[49]
If patients are on high dose of inotropes or vasopressors
and need excessive volumes of fluids for resuscitation, due
to chances of sub‑clinical ischemia or reperfusion injury
to the gut, enteral nutrition should be withheld.[50]
As bowel sounds are indicative of contractile movements
and it is not necessary that these indicate integrity of bowel
mucosa, absorptive capacity and barrier function. Main
reasons for intestinal dysfunction in critically ill patients
are mucosal barrier dysfunction, mucosal atrophy, reduced
gut‑associated lymphoid tissue and dysmotilty.[50,51]
Hence in critical patients, neither the presence or absence
of bowel sounds and passage of stools is mandatory for
initiating enteral feed.[51] And also if sick patients show
intolerance to gastric feeding, are at high risk of aspiration
and have high residual volume, can be started on small
bowel feed. There is also an evidence that if early enteral
nutrition has not been started within 7 days, parenteral
nutrition can be started.[50] As permeability if intestine
increases during 1st week of severe burns, there is need
to provide > 50–65% of the desired target. During first
7–10 days, parenteral nutrition supplementation has not
been found out to be helpful. Braunschweig et al. and
Sandström et al. have also concluded from their study
that after first 7–10 days, requirement for proteins and
energy are increased in order to prevent complications
due to poor nutritional status. Thus, if we are unable
to meet the energy requirement of the sick patient by
100% of the target level needed, parenteral nutrition can
be supplemented.[43,51] Studies in the literature have also
shown that those patients who receive larger volume of
enteral nutrition, encounter less complications and thus
less associated morbidity than patients receiving lower
feed amount.[43,53] There are various indications of enteral
nutrition as listed in Table 1.
Obese patients are at higher risk of infections, deep
vein thrombosis, insulin resistance, etc., So protein
supplementation in a dose of 2–2.5 g/kg of ideal body
weight/day and 60–70% of caloric requirement enhance
neutral nitrogen balance and promote wound healing.[52]
To prevent problems associated with ileus and inadequate
nutrient delivery, time for fasting before or after any
procedure should be kept minimum possible.[50]
Various tests are needed in patients receiving total
parenteral nutrition in the form of total blood count, B12
and folate levels, serum magnesium, phosphate, calcium,
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Bajwa and Kaur: Nutrition in burn patients
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glucose, liver function tests, serum albumin, prealbumin,
C‑reactive protein zinc and copper levels. Investigations
to be done in patients on total parenteral nutrition have
been mentioned in Table 2, as written below.
Frequency of tests can be reduced once the patient is
stable. Complete attention should be given to peripheral
lines for signs of thrombophlebitis and centrally sited lines
for signs of infection or inflammatory changes.[54]
Dietary Modifications in Special
Situations
Endocrine disorders
It has also been studied in the literature that normal
functioning of many endocrine organs like thyroid,
pancreas etc., is also linked to the nutritional status.
Thus nutritional imbalance can hamper their normal
functioning. Various endocrine disorders such as obesity,
thyroid disorders and diabetes have been linked with
dietary modifications. Increased prevalence of endocrine
disorders have been seen with over nutrition. Dietary
patterns actually programme the different mechanisms
associated with these disorders. As in case of diabetes
mellitus, presence of transcription factor TCF7L2 has
been linked, which can be regulated by fat and glucose
rich diet. All the dietary components affect endocrine
system of body.[55]
Chronic kidney disease
Dietary modifications both improve symptomatology
as well as progression of kidney diseases. Many factors
like type and severity of renal disease, nutritional status,
dry weight, dietary intake, co‑morbid diseases, physical
activity, biochemical markers and also the adjusted body
weight help in calculation of energy requirement of these
patients.[56]
Challenging Aspects
Present challenges and possible measures which can be
taken in developing countries may include but are not
limited to:
• Limited availability of indirect calorimetry in ICU
• Scarcity of availability of bio‑markers of illness, which
can improve in molecular basis of the different
pathological conditions
• Extensive search is needed in field of tight glycemic
control, pharmaco‑nutrition and immune‑nutrition
• Need to carry out randomized control trials and studies
to make guidelines
• Lesser funds are available for health services.
Our own guidelines and recommendations should be
made according to the Indian scenario after extensive
research and studies. These guidelines need to be followed
strictly in ICU as per the institutional resources. Training
programmes should be conducted for training of the staff.
Limitations
Limitations of current review article may include but are
not limited to lesser number of randomized controlled
trials, paucity of universal guidelines, different beliefs
and cultural practices in our country, different food fads,
socio‑religious factors etc., which can have either direct or
indirect effect on the nutritional aspects in burn patients.
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Source of Support: Nil. Conict of Interest: None declared.
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