Clinical Connections

April 16, 2014

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Stacey Hilliard RD, LDN

Rick Varner RD, CDE, LDN

NUTRITION AND THE BURN PATIENT

• Prevent weight loss

• Preserve lean body mass

• Promote healing

GOALS OF NUTRITION THERAPY

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• ASSESS PATIENT WITHIN 48 HOURS (TRY 24 HRS)

• FOLLOW UP WITH THE PATIENT EVERY 3 DAYS

• WEEKLY MULTIDISCIPLINARY BURN ROUNDS

RESPONSIBILITIES OF THE DIETITIAN

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Clinical Connections

April 16, 2014

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EBB PHASE NUTRITION

• Ebb Phase

– 2 – 48 hours post injury

– Metabolic shock

– Blood shunted away from major organs

– Decreased energy needs

FLOW PHASE NUTRITION

• Flow Phase – Hemodynamic stabilization

– Metabolic stress • “Fight or Flight” response activated by hormones

– glucagon, cortisol, epinephrine, norepinephrine

– Hypermetabolism & catabolism • glycogenolysis/gluconeogenesis

• free fatty acid mobilization

• protein syntesis, breakdown of skeletal muscle

– Hyperglycemia

– Increased energy and protein needs d/t increases in: • REE, O2 consumption, body temp., cardiac output

RECOVERY PHASE NUTRITION

• Recovery Phase

– Return to anabolism

– Energy/protein needs approach normal

– Eating patterns return to normal

Clinical Connections

April 16, 2014

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• HEIGHT

• ADMIT WT

• USUAL WT

• % TBSA

• FOOD ALLERGIES / INTOLERANCES

• DIFFICULTY CHEWING / SWALLOWING

• SUPPLEMENTS PRIOR TO ADMISSION

• PREVIOUS GASTROINTESTINAL ISSUES

• PREVIOUS SUBSTANCE ABUSE?

ESSENTIAL INFORMATION REQUIRED

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CALCULATING ENERGY NEEDS

ASSESSING THE BURN PATIENT

• J.B. is a 30 year old male who sustained ~ 25%

TBSA when he poured gasoline onto a campfire

• + ETOH on admit

• Intubated

• No inhalation injury

• Burns are partial and full thickness

• S/P excision

Clinical Connections

April 16, 2014

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CALCULATING ENERGY NEEDS

HARRIS BENEDICT EQUATION:

Female:

655 + (9.6 x kg) + (1.7 x cm) – (4.7 x age)

Male:

66 + (13.7 x kg) + (5x cm) – (6.8 x age)

Stress Factors:

• 1.2-1.4 = <20% TBSA

• 1.6 = 20-25% TBSA

• 1.7 = 25-30% TBSA

• 1.8 = 30-35% TBSA

• 1.9 = 35-40% TBSA

• 2.0 = 40-45% TBSA

• 2.1 = >45% TBSA

FACTS

• J.B. is 6’2” and 198 lbs (104% IBW)

• 25% TBSA

• 30 years old

Estimated EEN using HBE:

• 66 + (13.7 x kg) + (5x cm) – (6.8 x age) =

• 66 + 1233 +939.8 – 204 = 2035 kcal / day

• 2035 x SF (1.6 – 1.7) = 3256 – 3460 kcal / day

PROTEIN NEEDS

• 20-25% total kcal /day

• If the burn is > 20% TBSA use 25% total kcal

In J.B.’s case 20-25% total kcal (3256–3460 kcal)

Protein needs = 173-204g

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April 16, 2014

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FEEDING

• If patient cannot eat (ex: intubated / or

dysphagia) preferred method is enteral

nutrition

• High kcal / High protein formula

• Arginine / Glutamine

• Omega 3 Fatty Acids

TUBE PLACEMENT & ADVANCEMENT

• Post pyloric

• Start at ½ goal rate increase as tolerated

toward goal

• Monitor for residuals greater than 400 ml

J. B.

• In this case based on UPMC Mercy formulary I

would select Pivot 1.5 with goal rate of 90 ml / hr

x 24 hours (3240 kcal, 204g protein and 1639 ml

fluid).

• Once patient fully resuscitated – fluid

recommendations as usual. (ie.:250 ml free H20

q 4 hours.)

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April 16, 2014

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GI ISSUES

• Diarrhea – If on antibiotics

• Ileus – decreased GI motility due to pain

medications

• Gastroparesis – decreased GI motility most

common with poorly controlled diabetes

SUPPLEMENTS

• MVI

• VITAMIN C = 500 mg TWICE DAILY

• ZINC SULFATE = 220 mg ONCE DAILY

• VITAMIN A = 10,000 IU DAILY

ADDITIONAL CONSIDERATIONS:

• Oxandrin – patient must be receiving adequate

protein.

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April 16, 2014

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PARAMETERS TO MONITOR

• Weekly Weight

• Prealbumin • 2 x week if ≥20% TBSA; 1 x week if <20% TBSA

• Electrolytes

• % TBSA

• CRP

• Glucose – goal for control • Critical care – 140-180 mg/dl

• Non Critical care – <140 mg/dl (pre- meal)

– <180mg /dl (random)

INTACT MILD MODERATE SEVERE

16-40 mg/dL 10-15 mg/dL 5-10 mg/dL <5 mg/dL

PREABLUMIN

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ONCE EXTUBATED

• Speech evaluation for safe swallowing

• Advance diet

• Cycling of tube feeding

• Addition of oral supplements

• Education on high protein / high calorie

foods

• Education on status of prealbumin

• Food preferences / tolerances

• Calorie counts

Clinical Connections

April 16, 2014

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J.B.’s NORMAL DAILY PROTEIN

J.B.’s BURN DAILY PROTEIN

HIGH CALORIE / HIGH PROTEIN MEAL

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April 16, 2014

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FOODS / SUPPLEMENTS

ITEM PROTEIN KCALS

3 oz meat 21g 165-300

2 EGGS 14g 150

½ Cup Cottage Cheese 14g 120-150

1TBSP Peanut butter 7g 100

2 Strips Bacon 7g 100

1 oz Cheese 7g 75-100

Milk (8oz) 8g 80-150

Yogurt(6oz) 5g 100-170

Greek Yogurt(6oz) 11-16g 150

Boost VHC 22g 530

Ensure Complete 13g 350

Ensure Immune Health 9g 250

LiquaCel 16g 90

INCREASING PROTEIN INTAKE

• Double protein portions all meals

• Peanut butter

• Milk x 2 all meals

• Oral supplements

• Yogurt all meals

• Puddings

• Cottage cheese

• Protein modules

• HS snack

ROAD BLOCKS

• Nausea / vomiting

• Diarrhea / constipation

• Depression

• Unable to use fingers or hands,

burned lips, sore mouth or throat.

• Missing meals for hydrotherapy (meal timing / do

not hold tube feeding)

• No appetite / not normally a big eater

• Pain

• Bored with food choices / LOS

Clinical Connections

April 16, 2014

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PARAMETERS TO MONITOR

• Weight weekly

• Any change in %TBSA

– Recalculated weekly or after surgery

– Can be readjusted

• Prealbumin

• Oral intake / calorie counts

• Any GI issues

PEDIATRIC PATIENT

Mayes Formula

• Patients younger than 3 years of age

Mayes 1 = 108 + 68W + 3.9 x %burn

Mayes 2 = 179 + 66W + 3.2 x %third-degree burn

• Patients >3 to 10 years of age

Mayes 3 = 818 + 37.4W + 9.3 x %burn

Mayes 4 = 950 + 38.5W + 5.9 x %third-degree burn

CALCULATING ENERGY NEEDS

Clinical Connections

April 16, 2014

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CALCULATING ENERGY NEEDS

Category Age (y) Maintenance/kg +% burn kcal/d

Infants 0-1 98-108 +15 x %TBSA

Children 1-3 102 +25 x %TBSA

4-6 90 +40 x %TBSA

7-10 70 +40 x %TBSA

Male 11-14 55 +40 x %TBSA

15-18 45 +40 x %TBSA

Female 11-14 47 +40 x %TBSA

15-18 40 +40 x %TBSA

DIET

• Age appropriate diet

– Obtain food preferences from family if available

– Educate family on high protein / high kcal foods

Poor intake / or larger burns

• Calorie counts

• Appetite Stimulant

• ex: Periactin often used in pediatrics

• post-pyloric tube feeding can be used

ex: PediaSure 1.5 (specialized for pediatric pts.)

or

1.0 kcal/ml, low-fat formula is recommended for

pediatric burn pts. w/ increased needs

PREALBUMIN

Age Male (mg/dl) Female (mg/dl)

1-40 days 3.2 – 15.9 4.2 – 14.4

41-90 days 2.7 – 17.6 2.5 – 21.9

3-9 months 7.3 – 27.9 5.3 – 25.0

10-24 months 6.7 – 28.5 7.3 – 33.7

2-10 years 6.9 – 31.2 8.0 – 35.2

11-15 years 6.3 – 33.5 8.6 – 40.7

16-18 years 8.0 – 41.6 13.7 – 44.1 Pediatric Reference Ranges, Stephen J Soldin ed, AACC Press, 4th Edition

2003, p. 154

Clinical Connections

April 16, 2014

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PEDIATRIC SUPPLEMENTS

• Children’s MVI daily (Polyvisol 1 ml/day)

• Vitamin C • Children 1-2 years (< 40 lbs) = 100mg twice daily

• Children 2-3 years ( <40 lbs) = 250mg twice daily

• Children > 3 years (<40lbs) = 500mg twice daily

• Zinc Sulfate • Children 1-2 years (<40 lbs) = elemental zinc 100mcg / kg / day

• Children > 2 years (<40 lbs) = elemental zinc 5mg / day

• Children 2-12 years (>40 lbs) = elemental zinc 10mg / day

• Children > 12 years = 220mg / day

OBSTACLES WITH PEDIATRICS

• Must obtain food preferences from family

• Family dynamics

• Patients are not able to communicate needs

References

• Chan MM, Chan GM. Nutrition Therapy for burns in children and adults. Nutrition 2009;25: 261-269.

• Graves C, Saffle J, Cochran A. Actual Burn Nutrition Care Practices: An Update. J Burn Care & Research. 2009;30(1): 77-81.

• Gottschlich MM, Fuhrman PM, Hammond KA, Holcombe BJ, Seidner DL, Chapter 19: Burn and Wounds Healing. The Science and Practice of Nutrition Support, A cased –Based Core Curriculum. American Society for Parenteral and Enteral Nutrition. Kendall / Hunt 2001, 412-415.

• DeLegge MH, Mattox T, Muller C, Worthington P. Trauma, Surgery, and Burns. The ASPEN Nutrition Support Core Curriculum: A Case-Based Approach-The Adult Patient. 2007; 467-468.

• Nelms M, Sucher K, Long S. Metabolic Stress. Nutrition Therapy and Pathophysiology. Belmont, CA: Wadsworth: 2007. p.786-801.

• Nelms M, Sucher K, Lacey K, Long Roth S. Metabolic Stress. Nutrition Therapy and Pathophysiology, 2nd ed. Belmont, CA: Wadsworth: 2011. p.684-698.

• Mayes T et al. Evaluation of predicted and measured energy requirements in burned children. J Am Diet Assoc, 1996;96(1):24-29.

• Takecomo C, Pediatric Dosage Handbook 17th edition, Lexicom Publishing (2010-2011).

• Custer J, Rau RE, Harriet Lane Handbook 18th edition, John Hopkins Hospital 2008.

• Micromedix 2011