NUTRITIONAL MANAGEMENT OF THE SEVERELY INJURED PATIENT

Vitale R., Di Salvo L.*, Cucchiara R, D'Arpa N., Masellis M.

Divisione Chirurgia Plastica e Terapia delle ustioni Osp. Civico USL 58 Palermo, Italia
* Farmacia, Osp. Civico USL 58 Palermo

SUMMARY. In the bum patient caloric-proteic reintegration is a therapeutic moment of fundamental importance since the prevention or reduction of catabolism by means of adequate nutrition can preserve organic functions and reduce morbidity and mortality. The main objective is to satisfy the patient's caloric-proteic needs, by attempting to administer the maximum amount possible within 3 or 4 days post-bum. This triggers a catabolic braking mechanism. Accurate assessment of the patient's nutritional state on admission and during hospitalization is of fundamental importance, and a number of chemical, biohumoral, anthropometric and immunological reference parameters are used. A description is given of the different types of nutritional support administered (Total Enteral, Enteral with Supporting Parenteral, Total Parenteral) and of the necessary tests, indications and counterindications.

The most evident effects of increased catabolism in the severely burned patient (lvilmore), due also to caloric consumption following the inevitable evaporation of water (9), are alterations of the immunocompetent system and increased susceptibility to infection (3).
These patients need an increase in nutrition, of between 50 and 125% compared to base values. The prevention or inversion of cellular dysfunction by adequate nutritional intake can preserve organ functionality and reduce morbidity and mortality.
Our objective in such cases is to satisfy the caloric-proteic need by trying to reach the maximum possible quantity that can be administered within 3-4 days, in order to trigger a catabolic braking mechanism, no attempt being made to achieve early nitrogen balance.

- Quantification of denutrition - Identification of the high-risk patient - Efficient monitoring of nutritional support The following reference parameters are used:

Clinical

• Weight loss
• Oedemas
• Anorexia
• Vomiting
• Diarrhoea
• Chronic diseases
• Reduced pannicolus adiposus
• Reduced muscular mass

Anthropometric

• Tricipital fold
• Arm circumference
• Muscle circumference

Bioliumoral

• Scrum albumin
• Serum haemoglobin
• Serum transferrin
• Scrum iron
• RBP
• Prealbumin
• Creatinuria
• Creatinine/height index

Immunological

• Lymphocyte count
• C3c
• Skin test

As it was difficult to perform the nitrogen balance test in a bum patient on mixed nutrition, the following parameters were considered in order , to assess the validity of the nutritional support: body weight, urea nitogen, total proteins, albumin, transferrin, creatinine, total lymphocytes.
A careful retrospective analysis of our patients with bums between 30 and 90% BSA confirmed that the degree of catabolism varied in relation to the extent of the burned areas.
Starting 48 hours post-bum, our protocol (Table 1) prescribes the introduction of a different quantity of calories and proteins in relation to the extent of the bum (8).
This type of nutritional support reduces the nitrogen loss that begins about day 6 and reaches a peak about day 10.
The nutritional support we administer is of three types:

1. Total Enteral
2. Enteral with Parenteral Support
3. Total Parenteral.

Total Enteral nutritional support (2, 5) prescribes the introduction of complete polymeric diets formulated with a Kcal n.p./gmN varying between 130/1 and 175/1, through a C-flex or polyurethane nasogastric tube. Administration by nutripump is constant for 18 hours, with an interval of 6 hours (24.00-6.00).
This protocol makes it possible to administer a maximum of 4000 kcal n.p. with 23 gm of nitrogen together with electrolytes, vitamins and oligoelements; it also ensures that the quantity administered corresponds to the quantity estimated in the nutritional assessment stage.
The enteral route is not however always in a condition to satisfy the nutritional demands of the burn patient, whose energy needs are considerable. If this should happen the caloric-proteic need must necessarily be integrated parenterally.
Supporting Parenteral Nutrition together with Total Enteral (2, 5) prescribes the infusion of electrolyte-enriched isotonic solutions of aminoacids, glucose and lipids, vitamins, oligoelements and insulin.
We are convinced that this type of treatment should be adopted in the great majority of patients -even in those who present no impairment of the gastrointestinal system - in order to supply the plastic substrate necessary to neutralize part of the nitrogen losses, to minimize the loss of lean body tissue and to maintain visceral protein synthesis.
SPN has no counterindications since it is essentially nothing more than a careful administration of substances which would in any case be infused into the bum patient through peripheral veins, i.e. glucose, proteins and electrolytes, with the sole exception of lipids which in SPN play in some cases an important role due to their high caloric power.

Protocol A

• Total volume 2,300 nil
• Calories n.p. 1,000 (561 G + 439 L)
• Nitrogen 6.4 gin

Protocol B

• Total volume 2,516 nil
• Calories n.p. 1,122 (561 G + 561 1
• Nitrogen 7.5 gin

Protocol C

• Total volume 3,000 nil
• Calories n.p. 1,308 (654 G + 654 L)
• Nitrogen 8.7 gm

Total Parenteral Nutrition (TPN) is adopted with patients in whom Enteral/Parenteral nutrition cannot be used to administer the necessary nutrients.
TPN must be adopted in the event of the onset of complications (diarrhoea etc.) in the course of Enteral Nutrition, requiring protracted interruption of treatment, or the onset of gastrointestinal haemorrhages or enteroparalysis.
In these and other particular cases the risks deriving from TPN are acceptable compared to the possible risks of caloric/proteic/hydric nonreintegration.

In the burn patient nutrition plays a primary role because the catabolic state leads to loss of weight, alterations in the immunocompetent system and increased susceptibility to infection.
Artificial nutrition has to be administered in order to attenuate these conditions.
In our Institute, starting 48 hours post-bum and in patients with integral gastrointestinal functionality, we initiate Enteral Nutritional treatment with peripheral parenteral support, and in particular when BSA exceeds 30% as in these cases it is necessary to administer considerable quantities of calories and nitrogen.
The onset of complications (diarrhoea etc.) and of pathologies not present at the time of admission (gastric haemorrhages, enteroparalysis) may make it preferable to employ total Parenteral Nutrition which, because of the risks this technique presents, is reserved for patients who offer no other alternatives that are more physiological, more easily managed or less risky.

RESUME. La réintégration calorique-protéique du brûlé représente un moment thérapeutique très important parce que la prévention ou la réduction du catabolisme peuvent protéger les fonctions organiques et réduire la morbidité et la mortalité. Le but principal est la satisfaction des besoins calorique-protéiques en tentant d'en administrer la quantité maximum entre 3-4 jours après la brûlure, ce qui déchaîne un mécanisme de freinage catabolique. Il faut absolument faire une évaluation précise de l'état nutritionnel du patient au moment de l'hospitalisation et pendant tout le séjour à l'hôpital. A cette fin on emploie divers paramètres de référence chimiques, biohumoraux, anthropométriques et immunologiques. Les Auteurs décrivent les divers types de soutien nutritionnel (Entéral Total, Entéral avec Soutien Parentéral Total) et les tests relatifs, les indications et les contre-indications.

BIBLIOGRAPHY

1. Bellantone R., Doglietto G.B., Bossola M., Pacelli E, Crucitti F: La risposta metabolica at "Trauma". Atti 35 Cong. Soc. It. Ch. Plastica, Milano 25-27 Sett., Ed. Mondrizzi, 1986.
2. McArdle A.H., Paimasona R.T., Browria A., et at.: Protection from catabolism in major bums: a new formula for theimmediate enteral feeding of burn patients. J.Bum Care Rehab. 4: 245-249, 1983.
3. Meakins J.L., Piersch J.B., Bubenick 0., Kelly R., Rode H., Gordon J., MacLean L.D.: Delayed hypersensitivity: indicator of acquired failure of host defenses in sepsis and trauma. Ann. Surg., 186: 241, 1977.
4. Michael F. et al.: Contemporary Surgery, 13: August, 1978.
5. Mochizuki H., Trocki 0., Dominioni JW., et al.: Mechanism of prevention of postbum hypermetabolism and catabolism by early enteral feeding. Ann. Surg., 200: 297-310, 1984.
6. Muggia-Sullam M., Bower R.H., Murphy R.F., et al , : Postoperative enteral versus parenteral nutritional support in gastrointestinal surgery. Am. J. Surg. 149: 106-112, 1985.
7. Wilmore D.W.: Nutrition and metabolism following thermal injury. Clin. Plas. Surg., 1: 603, 1974.
8. Wolfe R.R., Goodenough R.D., Burke J.F., et al.: Response of protein and urea kinetics in bum patients to diferent levels of protein intake. Ann. Surg., 197: 163-171, 1983.
9. Zawacki B.E., Spitzer K.W., Mason A.D. Jr., Johns L.A.: Does increased evaporative water loss cause hypermetabolism in burned patients? Ann. Surg., 171: 236, 1970.