SUMMARY. Authors discuss the choices of nutritional support in patient after severe burn injury during the last three decades. Severe burn injury presents one of the most critical states of starvation under a severe stress to the organism. Timely and appropriate metabolic intervention can positively influence the hypermetabolism, which is a common reaction after an injury. Burn injury causes a long-term reaction with a great risk of multiple organ dysfunction (requirement to perform repeated dressing changes under general anesthesia, repeated surgeries, and infections). Incorporation of a nutritional support is based on the knowledge of pathophysiology and metabolic response to injury, and is influenced by choice of nutrition substrates and by possibility of its administration. .
Die Autore Die Autore beschreiben die Möglichkeiten der Nahrung als eine Therapieunterstützung bei den schwer verbrannten Patienten während der letzten Jahrzehnte. Ein schweres Verbrennungstrauma gillt für den schwersten Hungerzustand unter StressBedingungen. Durch frühzeitige and entsprechende metabolische Intervention kann der Hypermetabolismus, eine übliche Reaktion auf die Verletzung, beeinflusst werden, Das Verbrennungstrauma stellt eine Stressreaktion mit hohem Risiko einer Organ-Dysfunktion dar (Erneuerung von Verbänden, wiederholte chirurgische Eingriffe and Infektion). Die Nahrung als eine Therapieunterstützung wird von der gegenwartigen Kenntnisse auf dem Gebiet der Pathophysiolog and metabolischer Reaktion auf das Verbrennungstrauma, der Auswahl von Nahrungspräparaten and der Möglichkeiten ihrer Verwendung beeinflusst.
Key words: parenteral nutrition, enteral nutrition, immunomodulation
Nutrition in patients with burn injuries was until the 1970s provided by tube and oral feeding. It depended on patient's status and was prepared individually for each patient. Parenteral nutrition was based on a sugar solution with ions and vitamin supplements. The 1970s and 1980s were a significant period for the development of nutritional support for patients with burn injuries. During this period, total parenteral nutrition (TPN) started and clinically expanded. It allowed application of sugar-based solutions as well as balanced aminoacids solutions, organ specific solutions, and lipid emulsions. In Czechoslovakia, Kruf and Petrásek, who cooperated closely with the Prague Burn Centre implemented TPN. Enteral nutrition was defined at the same time by Nejedly: Defined Liquid Nutrition - so-called Kladno nutrition. The Czech industrially made formula for enteral nutrition - Nutramin Mpulvis was introduced. Foreign-based formulae were not accessible at that time. Nutritionalneeds of a patient were reappraised and hyperalimentation (causing fevers, hyperglycemia, increased production of CO,, steatosis and dysfunction of liver, increased demands for urea clearance and renal function) was eliminated.
In the 1980s and 1990s, nutrition was oriented to the needs of a patient and his actual status. Its main goal was a reduction of hypermetabolism. Once the patient was stable, nutrition was focused on the anabolic goals. In patients with burn injuries, the rehabilitation phase starts, when all the burned areas are closed. To focus on administration of the basic nutrients (sugars, lipids, proteins), water, electrolytes, and micronutrients (vitamins and trace elements) in enteral nutrition is a priority.
In the last 10 years, comprehensive nutrition includes immunomodulation, incorporation of additives with potential influence over the immune system (for example glutamine, arginine, nucleotides, omega 3 fatty acids, glycine, antioxidants etc.). The access of foreign pharmaceutical manufacturers to our market extended the possibilities to use wide spectrum of products for application of parenteral and enteral nutrition.
Parenteral nutrition is essential after a severe burn injury. TPN is used exceptionally in dysfunctional gastrointestinal tract (GIT). In the long term, supplemental parenteral nutrition in conjunction with the enteral nutrition ensures sufficient intake of fluids, electrolytes, and nutrients.
Enteral nutrition (EN) should be used if the GIT is functional. Failure to use EN in critical condition is associated with atrophy of the mucous membrane, intraluminal bacterial multiplication, and translocation to portal circulation. Early EN has a positive impact on the progress of treatment. It is necessary to choose the appropriate approach to nutrition - oral, gastric, jejunal, according to the condition of a patient.
Current nutritional approach in a patient with severe burn injury analyzes the degree of stress to the organism (the extent of burn, interval from the accident, possible complications-infections, organ dysfunctions). The choice of an appropriate nutrition product, best way of administraiten and timely start is important. Monitoring of the patient's nutritional status is necessary, despite oftenlimited anthropometrical readings, biochemical monitoring, immunological assessment, and possibly indirect calorimetry is possible. Nutritional support is not just a substitute to a normal food, but also part of a comprehensive care that involves pharmacotherapy. It should be adjusted individually, according to the clinical condition of the patient.
Address for correspondence:
J. Kripner, M.D.
Prague Burn Centre
Srobárova 50
100 34 Prague 10
Czech Republic