Annals of Burns and Fire Disasters - vol. XX - n. 1 - March 2007

NUTRITIONAL INTERVENTIONS IN SEVERE BURNS IN CHILDREN - THERAPEUTIC RESULTS

Spodaryk M.¹, Pucha J.²

University Children’s Hospital of Cracow, Poland
¹ Department of Paediatrics, Gastroenterology and Nutrition
² Division of Plastic and Reconstructive Surgery, Paediatric Burns Centre

SUMMARY. This paper, which supplements the theoretical articles already published in Annals of Burns and Fire Disasters (vol. XVIII, pp. 117-21, 2005), presents the therapeutic results achieved in 37 extremely burned paediatric patients. The clinical analysis included nutritional protocols and methods of monitoring treatment effectiveness. The necessity of introducing nutritional intervention immediately after initiation of severe burns treatment is unquestionable, the aim being to decrease catabolism in the initial period of the burn disease followed by the achievement of the appropriate metabolic determinants of wound healing.

Introduction

Nutritional treatment is an element of combined therapy in the most severe thermal injuries, permitting a decrease in tissue catabolism and appropriate wound healing. The necessity of introducing nutritional interventions is unquestionable.

The metabolic situation presented previously, which decreased exogenous glucose and fat emulsion tolerance, dramatically hindered nutritional treatment.3,4 The maximum daily glucose supply in patients after thermal injury should not exceed 3/7/10 g/kg of body weight.3,4 When the dose exceeds the tolerance level, the patient develops hyperglycaemia and metabolic acidosis, which makes calculation of caloric intake by the Harris-Benedict or Curreri equations impossible.

The issue of appropriate nutrition was solved by introducing the “Strategy of nutritional intervention in severe thermal injuries - the management algorithm”, presented in Part 2 of the above papers.

Material

The analysis included nutritional treatment as an element of combined therapy in 37 severely burned children. The mean surface of full-thickness skin damage (n = 37) was 45.5 ± 13.6% total body surface area (TBSA). The most frequent burn wound locations were the upper and lower extremities, the back, the chest, and the buttocks.

The clinical data of the patients analysed are presented in Table I.

Method

In each patient, wound debridement followed typical surgical procedures. In 31 cases with circular wounds involving the extremities, fasciotomies were performed. On average, necrotic tissue was gradually excised starting on day 3 post-injury, the excised area not exceeding 15% TBSA in each procedure. When the wound surface was fully debrided, the wound was covered with split-skin grafts harvested from the patient. The grafts were 0.1-0.2 mm thick and meshed to a ratio of 1:3 and/or 1:6. In the group presented, appropriate conditions for skin grafting were achieved between days 5 and 7 post-injury. When the patient was stabilized and fluid resuscitation was completed, on day 2.6 ± 1.0 post-injury, parenteral nutrition was started. The amino acid infusion rate was regarded as the key value in calculating the parenteral nutrition solution composition. The energy supply was calculated on the basis of the ratio between non-protein calories and grams of nitrogen, determining the optimum values as 150-200:1. The accepted premise was that the daily amino acid supply was dependent on the patient’s age and body mass. The parenteral nutrition solution that was used supplied crystalline amino acids at a mean rate of 1.5 ± 0.5 g/kg/day. The protein supply was supplemented by enteral artificial diets in order to reach a mean value of 2.6 ± 0.4 g/kg/day. The early introduction of enteral feeding (on average on day 3.9 ± 2.4 post-injury) was possible thanks to continuous infusions to the jejunum of commercially available elemental formulas, which permitted the use of a gastrointestinal access in view of persistent gastric collection, maintained for a mean period of 7.3 ± 2.0 days. Owing to intensified lipolysis, the contribution of fat emulsions in the implementation of the calculated metabolic requirements was reduced to 25–30% of non-protein calories at infusion rates not exceeding 0.15-0.17 g/kg/h. The complete intravenous nutritional solution, pre-packed in an infusion bag, contained amino acids, glucose, fat, electrolytes, vitamins, and trace elements according to the “All-in-one” principle.

Results

The effect of the therapeutic management adopted is best illustrated by the fact that regardless of the extent of full-thickness skin damage, all the children survived. Standard tests employed in burned patient status monitoring did not show any major deviations from reference values; the results are presented in Table II.

Conclusion

The advantages of the therapy employed were the accelerated wound healing and the easier take of the skin graft harvested from the patients, as well as the fact that the skin graft harvesting sites were ready for repeated graft collection sooner. The duration of treatment was shortened, especially as regards the emaciation-causing tissue catabolism period. Prior to introduction of this treatment protocol, complete wound healing had not been achieved in less than 8-12 weeks after thermal injury. In the present group, the time did not exceed 6-8 weeks. It also appears that the final effect (scarring) was more satisfactory from the cosmetic point of view.

This protocol of combined surgical-nutritional management of burned children was deemed by a multispecialist burn team to be appropriate and effective, permitting a reduction of the duration of treatment and reducing the number of complications due to the metabolically disadvantageous “starving” or “overfeeding” of the patient.

RESUME. Dans cet article, qui supplémente les travaux théoriques déjà publiés dans Annals of Burns and Fire Disasters (vol. XVIII, pp. 117-21, 2005), les Auteurs présentent les résultats thérapeutiques obtenus chez 37 patients pédiatriques sévèrement brûlés. L’analyse clinique incluait les protocoles nutritionnels et les méthodes pour contrôler l’efficacité du traitement. La nécessité d’effectuer une intervention nutritionnelle immédiatement après le commencement du traitement des brûlures sévères est incontestable: le but est de diminuer le catabolisme dans la période initiale de la maladie brûlure et ensuite d’arriver aux déterminants métaboliques appropriés de la guérison des lésions.

Bibliography

1. Koller J., Kvalteni K.: Early enteral nutrition in severe burns. Acta Chir. Plast., 36: 57, 1994.
2. Spodaryk M., Puchala J.: Early total parenteral nutrition employing TPN v.1,2 PATIsoft software in the treatment of children with massive burns. Surg. Childh. Intern., 2: 96-9, 1997.
3. Spodaryk M., Kobylarz K.: The usability of Harris-Benedict and Curreri equations in nutritional management of thermal injuries – Part one. Annals of Burns and Fire Disasters, 18: 117-9, 2005.
4. Spodaryk M., Kobylarz K.: The usability of Harris-Benedict and Curreri equations in nutritional management of thermal injuries – Part two: Strategy of nutritional intervention in several thermal injuries - the management algorithm. Annals of Burns and Fire Disasters, 18: 119-21, 2005.
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