Nutrition for Burn Victims

When a person is burned, especially with second degree burns or third degree burns, there is a rapid change in the way the fluids are distributed throughout the body as well as in the body’s metabolic needs.  This means that doctors must provide nutrition for the burn  victim  that promotes healing and hemodynamic stability.
 
The metabolic rate (the rate in which calories are burned by the body) can more than double after a major burn.  The burn victim has increased energy and protein demands and failure to satisfy those needs means wounds won’t heal properly and infection is more likely.  Organs can fail as a result of serious burns and this can lead to death.
 
Nutrition support for burn victims is complicated and not all research studies on the topic agree with one another.  Some of the research has been done on non-trauma victims and has been extrapolated to include work on burn patients but it is unknown if there is one perfect way to treat these kinds of patients.
 
How does hypermetabolism work?
 
When a patient is burned, the body releases large amounts of the catabolic hormones, particularly cortisol, glucagon, and epinephrine.  These hormone levels remain elevated for days after the injury.   The blood sugar rises and the synthesis of protein and fat is reduced.  It means that the diet of the burn victim must be very high in protein so skeletal muscle isn’t wasted.
 
There are things the medical staff can do to lessen the caloric needs of the burn victim.  For example, the ambient temperature can be set higher  and the relative humidity can be increased to reduce caloric needs.  When the burn is excised and replaced by  an autograft or allograft, the need for calories is also reduced.  These things are simple measures that can reduce the hypermetabolism of the body.
 
Doctors can calculate the metabolic needs of the patient through the use of several different formulas for adults and children alike.  They are based on the patient’s baseline weight as well as the estimated body surface area burned.  The greater the burn, the more are the caloric requirements.  One of the problems with these calculations is that the patient’s metabolic needs are different as the patient heals.  They are often overfeeding the patient in the early and late days of the burn and underfeeding when the metabolic needs are the greatest.
 
What to feed the burn patient…
 
The burn victim needs most of his or her energy from carbohydrates, especially from glucose as this helps wounds heal the fastest.  Unfortunately, the acute burn victim develops insulin resistance such as is seen in type 2 diabetics.  For this reason, both glucose and insulin must be given in doses that allow the glucose to get into the cells.
 
Large amounts of protein must be given in amino acid form as part of parenteral nutrition.  There is even a place for fat intake when dealing with burn victims.  Most experts recommend a diet containing essential fatty acids that does not exceed 30 percent of non-protein calories.  It is best to provide the patient with omega-3 fatty acids because they are metabolized easily without liberating inflammatory metabolites.  Omega-3 fatty acids are beneficial in improving the immune system of the burn victim.
 
Proteins are broken down rapidly from skeletal muscles and other areas of the body in burn victims.  Patients can lose up to a half a pound of skeletal muscle per day after sustaining a large burn.  It is therefore recommended to use up to two grams of protein per kilogram of patient weight per day.
 
Two amino acids, alanine and glutamine, are important proteins in healing wounds and in supplying energy to the liver.  Glutamine helps support the gut’s immune
function and is a precursor to making glutathione, which is an important antioxidant.  It helps protect the cells after traumatic stress to the body.  It is, however, unstable in a liquid medium so it isn’t something that can be added to total parenteral nutrition in the burn victim.  It is supplied separately from other nutrients the body gets.  Arginine is also helpful in the burned patient as it stimulates T lymphocytes and enhances natural killer cell abilities in the immune system.

Total Parenteral Nutrition

Total parenteral nutrition is the type of nutrition given to traumatized or sick patients that provides more than just salt and sugar solution.  Vitamins and macronutrients such as fats and protein are added to the liquid and fed into the patient’s veins.  TPN can be custom-made or purchased as a premade mixture of nutritional supplements.  Insulin and medications to protect the gut are added to TPN to help the nutrients get digested properly by the cells of the body.

TPN is unfortunately very expensive and may not offer many advantages over giving nutrients enterally (by putting the food through a tube into the stomach).  For this reason, most doctors now prefer providing enteral nutrition (EN).  EN protects the gut and allows the GI system to naturally absorb the necessary nutrients.  It also prevents too much fat from entering the body and prevents fatty liver complications that come out of using total parenteral nutrition.  In spite of the major insult burns cause the body, enteral nutrition can be started within hours after the burn injury.

Complications of Feeding the Burn Victim

One complication of providing nutrition to the burn victim is overfeeding the patient.  Surprisingly, overfeeding can cause more complications than underfeeding.  These include the following complications:
  • Increased carbon dioxide in the blood
  • Fatty liver
  • Azotemia (high BUN and creatinine)
  • Hyperglycemia
  • Dehydration and coma
  • Too high or too low potassium levels
  • Too high or too low sodium levels
  • Too high or too low magnesium levels
  • Too high or too low of phosphate levels
  • Deficiencies of trace minerals and other elements
  • Deficiencies of vitamins
  • Deficiency of fatty acids
There are specific complications that come out of giving enteral nutrition including puncturing of the bowel or death of a portion of the bowel wall.  There can be significant diarrhea due to overfeeding the gut and infections from cytomegalovirus or Clostridium difficile can contribute to diarrhea.  Even so, it is considered much safer than giving total parenteral nutrition.

A serious burn is a catastrophe. Anyone who has a serious burn thru the negligence of another should contact an experienced catastrophic injury lawyer.
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