Nutrition care process: In Burns

Yamini Prakash

Lead clinical dietician. Kauvery Hospital, Alwarpet, Chennai

Background

Promote wound healing
Maintain lean body mass
Restore fluid levels

Short-term goals

To improve oral intake and to prevent nutrition deficiencies.
To control inflammatory markers.
To use enteral feeds, ppn and other oral semi elemental supplementation if needed.

Long-term goals

To facilitate nutrition well-being–being of the patient.
To promote the quality life of the patient.

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

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.

Protein Requirements

Amino acids are important for collagen synthesis for wound healing. Maintaining visceral protein is important for organ function, especially for immune system. Maintaining intercostal muscles and the diaphragm is imperative for respiratory efficiency.

1.4-2.2 g/kg protein required for burn cases

Urinary nitrogen losses increase with the severity of the burn injury (Trauma patients may lose 20-25 g of lean body nitrogen daily).

Protein requirement estimate:

Combine 24-hr urinary nitrogen loss, 2 to 4 g of nitrogen for fecal loss, and 4 to 5 g/d for anabolism. 260 mg protein/kg/hr- muscle protein catabolism.
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, we get 20-25% of calories from proteins.

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

Nutrition Therapy

Always prefer oral intake if possible (Preserves GI function). 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.

Other areas to focus on: Albumin, vitamin C, vitamin D, zinc, vitamin A, copper, glutamin.

Subjective Global Assessment

S. No	Vitals	Results
1	Height	158 cm
2	Weight	69 kg
3	Body mass index	27.7 kg/m2
4	Ideal body weight	60-67 kg according to WHO patient is on moderately malnourished.
5	Diet habit	vegetarian with no onion and garlic
6	Food allergies	nil

Medical nutritional therapy

S. No	Nutrients	Uses
1	Energy	The energy needs of the patient vary depending upon the depth and size of the burn. However, for 35% burn, by using curries formula, the energy is calculated.
2	Carbohydrates	A liberal amount of CHO must be given i.e. 60-65% of the total calories, keeping in mind the maximum glucose tolerance of the patient and should also prevent hyperglycaemia
3	Protein	It is one of the most crucial nutrients which ultimately determines the outcome of burns. Amino acids requirement is high due to increased losses through urine and wounds, thus patients have to be given 20-25% of increased energy from protein.
4	Fat	A low fat diet is given during their initial phases of recovery due to altered GI function, gradually improving to a normal fat diet to provide adequate calories.
5	Fluids	Dehydration usually occurs as fluid seeps through the wounds so liberal amount of fluid must be administered.
6	Micronutrient	Micronutrient are administered as per RDA except in cases of abnormal level it must be corrected.

Nutritional prescription

S. No	Nutrients	Required amount
1	Energy	According to curries formula: 24 kcal+ usual body weight + 40kcal × %TBSA = 3200 kcals
2	Carbohydrates	60% of the total calories
3	Protein	25% of total calories
4	Fat	15% of total calories
5	Fluids	liberal amounts of fluids
6	Salt	6g/day
7	Vitamins	As per RDA
8	Minerals	As per RDA, Mg, calcium and potassium was administered as it plays an important role in tissue repair.

Assessment results

PPN

Oral

Case Presentation

A 64-year-old female was admitted to the hospital with 35% mixed burns over her body with severe pain and skin peeling, she was stable and conscious. She was initially administered with NJ feed and the main aim was to avoid any nutritional complications.

Since the patient was in a highly catabolic state, her energy needs were high and she was administered with NJ (Nasojejunal) feed + PPN (partial parenteral nutrition) +oral feeds during her conservative treatment, gradually NJ tube was removed as she got better with treatments and she was started with high protein oral feeds, which the patient tolerated well.

The patient was advised to follow a high protein diet to maintain tissue integrity and for wound healing.

KCH Clinical Dietician Team

Mrs. Renuka prasanth

Ms. Nalini shiv kumar

Mrs. Kamali

Nutrition care process: In Burns

Nutrition care process: In Burns

Yamini Prakash

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