Annals of Burns and Fire Disasters - vol. IX - n. 1 - March 1996

CONSIDERATIONS ON NUTRITIONAL THERAPY IN THE BURN PATIENT

Cucchiara R, Masellis M, Sucameli M.

Divisione di Chirurgia Plastica e Terapia delle Ustioni, USL 58, Ospedale Civico, Palermo, Italy

SUMMARY. A description is given of the nutritional therapy protocol used in the Palermo Burns Centre. This protocol recommends the enteral approach, but also uses parenteral support in the treatment of patients with burns in more than 25% body surface area. Enteral nutrition is without any doubt an effective therapeutic approach which prevents complications, in particular of the gastroenteric tract.

Nutrition is a therapeutic technique that can be compared to personalized infusion therapy and aimed antibiotic therapy. It is used to complement the treatment of seriously burned and/or polytraumatized patients, many of whom are also in a hypercatabolic state.
The choice of the type of nutrition, which is based on the patients' individual needs, their physical characteristics, the type and duration of the burn disease, and the presence of complications enables the physicians, on the basis of an accurate anamnesis and careful monitoring, to adopt the best possible approach.
In seriously burned patients with important alterations of the hydroelectrolytic and acid-base balances, the metabolic equilibrium is also affected. There is a tendency towards hypercatabolism, especially if early nutrition is not initiated (after the first 48 hours) with the administration of nutritional substrates which within a few days protect the digestive system, counteract infection and prevent malnutrition, by slowing down hypercatabolism. These patients require a calorie increase varying between 50 and 120% of basic energy requirements. The catabolic state is manifested in a deficit of the immunocompetent system and increased impairment of organ function, sometimes with fatal consequences. 1,4,5,6,7

In the Palermo Burns Centre we initiate our burn protocol 48 hours post-burn, preferring the enteral approach (Table 1), with the use of complete sernielemental polymer diets (in which the nutrients are present in easily digestible form and in balanced proportions, and require only a part of the digestive processes in order to be absorbed) with 1.5 kcal/ml, in addition to the normal diet of about 1600 kcal, either in oral boluses or by continuous infusion by means of a Nutripump and a nasogastric probe. In the first case we administer up to seven boluses at 3-hour intervals between 6 a.m. and midnight, in amounts increasing from 350 to 1750 ml, with a maximum caloric input of 2625 kcal (Table II); in the second case we infuse at varying rates between 30 and 125 ml/hr for 18 hours a day, with a maximum input of 3375 kcal (Table III).
The comparative analysis of nutritional preparations indicates their protein, glucide and lipid sources (Table IV). We would point out that monomer fonns (ditripeptides and crystalline AA) are assimilated more than other protein forms but also that when the intestine is intact there is no nutritional advantage in the use of monomer forms compared to polymer forms (whole proteins or protein hydrolysates).
In very catabolic patients in whom the enteral input is insufficient we use supporting parenteral nutritional therapy with 8.5% amino acids, 10-20% glucose and 10-20% lipids, providing a total input of about 2000 kcal (parenteral nutrition/nitrogen caloric ratio 130/1), with 12.5 gm of nitrogen in 3000 ml volume in a peripheral vein.
In rare cases when the patient is unable to take nutrients orally or by nasogastric probe we use parenteral nutritional therapy in a central vein, using 30% glucose, 8.5% amino acids and 20% lipids. We thus provide an input varying between 2700 and 3500 kcal with 18.75 gm of nitrogen .
Nutritional therapy is generally administered to patients with deep extensive bums in more than 25% BSA, especially if they present respiratory and/or septic complications.
The advantage of continuous monitoring, which at first sight may seem to be excessive, is that in these unstable patients some parameters may vary considerably during the arc of the day in relation to the phase of the bum: the samples are taken in sterile conditions in unburned areas at a frequency ranging between every four hours and once a day (Table V~. Body weight is very important and must be measured every time the patient is changed, by means of self-regulating computerized scales."I'l

In enteral nutritional therapy, if the administration is carefully planned and properly managed, the typical septic complications of parenteral nutritional therapy are absent, and side-effects, due mainly to the high osmolarity of certain dietetic preparations, are minimal (Table V1). It must be remembered that some drugs, including antiacids and H2 antagonists, can cause diarrhoea and that reduced gastric acidity can favour bacterial colonization of the nasogastric probe, causing gastroenteric disturbances and hyperthermia. These conditions are generally attributed to the nutrients and are often responsible for the suspension of nutritional therapy.

Cases of intolerance of the diet administered have been very rare, usually being due to small quantities of lactose in certain products rather than to mismanagement. These situations revert to normal with a modification of the modality of administration or, more rarely. by a brief suspension of administration or a change in the type of nutrient. Hyperglycaemia is easy to control, thanks to the monitoring of glycaemia and glucosuria, with venous or subcutaneous infusion of one unit for every 15 gm of glucose in normal conditions.

The complications during peripheral parenteral nutrition are infrequent and not serious. They are mainly cases of phlebitis that are easily resolved by changing the point of venous access or by increasing local blood flow by means of nitroglycerine plasters in order to prevent chemical phlebitis.
Complications arising during parenteral nutritional therapy involving a central vein are more serious, though rare: haernatomas in the jugular or femoral cannulation site, pneumothorax following subclavian cannulation, obstruction of the vein catheter due to maladministration of drugs or to blood reflux, and dislodging of the catheter during changing, bathing and wound dressing or because of psychomotor agitation in septic patients.
Sepsis sometimes occurs in patients in whom it is necessary to create access points in burned areas. In these cases hyperglycaemia is kept under control by careful monitoring and by continuous infusion of insulin either directly in the dripfeed or by means of a microinfusor at a rate of one unit per 5 gm.

Bum patients undergo a disruption of one or more of the balances that are necessary for the physiological state of the organism: this disruption is in part due to neuroendocrine and metabolic reactions to the burn trauma that differ from the norm; nutritional needs are also considerably increased.
It is not always easy to identify the altered functions immediately and to support or replace them artificially.
Enteral nutrition in the severely burned patient reduces the alterations caused by the trauma. It also prevents toxic infective complications, particularly those originating in the shock phase already in the first hours in the gastrointestinal tract, and improves the absorption of nutrients, giving patients a higher level of comfort, thanks also to the palatability of the diet. At the same time there is a direct therapeutic and systemic action on the digestive system.

RESUME. Les auteurs décrivent le protocole de thérapie nutritionnelle adopté dans le Centre de Brûlés de Palerme. Ce protocole recommande la voie entérale, avec un soutien parentéral dans le traitement des patients atteints de brûlures de plus de 25% de la surface corporelle. La nutrition entérale est sans aucun doute une technique thérapeutique efficace qui évite les complications, particulièrement celles de l'appareil gastro-intestinal.

1. Vitale R., Di Salvo L., Cueehiara P., D'Arpa N,, Masellis M.: Nutritional management of the severely injured patient. Arm. Medit. Burns Club, 2: 196-8, 1989.
2. Lown D. et al.: Use and efficacy of nutrition protocol for patients with burns in intensive care. J. Burn Care Rehabil., 13: 371-6, 1991.
3. Bellantone R., Doglietto G.B., Bossola M., Pacelli F, Crucitti F: La risposta metabolica al trauma. 35th Congr. Soc. It. Ch. Plast., Monduzzi, Milano, 1986.
4. MeArdle A.H. et al.: Protection from catabolism in major burns: a new formula for the immediate enteral feeding of burn patients. J. Burn Care Rehab., 4: 245-9, 1983.
5. Wolte R.R., Goodenough R.D. et al.: Response of protein and urea kinetics in burn patients to different levels of protein intake. Arm. Surg., 197: 163-71, 1983.
6. Mochizuki Il., Trocki 0., Dominioni LW: Mechanism of prevention of postburn hypermetabolism by early enteral feeding. Arm. Surg., 200: 297-310, 1984.
7. Garrell D.R. et al.: Length of care with severe burns with or, without early enteral nutritional support: a retrospective study. J. Burn Care Rehabil., 12: 85-90, 1991.
8. Ireton-Jones C.S. et al.: Nutritional considerations in recovered patients with burns. J. Burn Care Rehabil., It: 581-2, 1990.
9. Pearson K.S. et al.: Continuous enteral feeding and short fasting periods enhance perioperative nutrition in patients with burns. J. Burn Care Rehabil., 13: 477-81, 1992,
10. Paxton J. et al.: Nutrient substrates. J. Burn Care Rehabil., 12: 198-201,1991.
11. Dylewski-Feolorchok D. et al.: Vitamin C supplementation in the patients with burns and renal failure. J. Bum Care Rehabil., 13: 37880,1992.
12. Ireton-Jones C.S. et al.: The evolution of nutrition support in burns.J. Burn Care Rehabil., 14: 272-80, 1993.
13. Garret DR. et al.: nermogenic response to feeding in severely burned patients: relation to resting metabolic rate. Burns, 19: 467-72, 1993.
14. Ireton-Jones C.C. et al.: Does the use of an enteral feeding tube with a pH-sensitive tip facilitate enteral nutrition? J. Burn Care Rehabil., 14: 215-7, 1993.

15. Bracciale D.: Solutions to diarrhea. J. Burn Care Rehabil., 12: 278-81, 1991.