Recent Concepts in Nutritional Therapy in Critically Ill Burn

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110]
Original Article
Recent Concepts in Nutritional Therapy in Critically Ill Burn

Patients
Mariappan Natarajan
Department of Hand Surgery, Sri Ramachandra Institute of Higher Education and Research, Porur, Chennai
Abstract
In developing countries such as India, burn injury is still a major and frequent cause of mortality and morbidity. Nutrition therapy aims to
provide adequate and early nutrition for patients suffering from burn injuries. Metabolic support during heightened inflammatory state is
essential to make sure adequate treatment of burn patients. It is essential to reduce the force and effects of the hypermetabolic response, aim for
healing of wounds, and help to reduce negative catabolism effects. At the same time, care of surgical and medical needs of the patient is crucial
for good clinical outcomes. Nutritional sustain is an essential and integral component of burn care that requires an aggressive multifaceted
approach. Impaired wound healing, dysfunction of multiple organs, increased chances of infection, and death are largely prevented by an
adequate nutrition care along with proper wound management. Catecholamine and corticosteroids, inflammatory mediator levels, are
increased, and this hypermetabolic response leads to catastrophic results in the postburn injury period. A shift from preventing malnutrition to
disease modulation in nutrition support in critically ill patients is being aimed at present.
Uncontrolled inflammation causes severe metabolic derangement in burn patients. Major challenges are assessment of nutritional status of the
patient and estimation of nutrient requirements. Careful decision-making for safe use of enteral or parenteral nutrition and an aggressive
nutrient delivery are required. The course of disease can be altered favorably to a great extent by supplementation of specific nutrients.
Nutritional factors with positive effects on immunity and in cell regulation include glutamine, arginine, and essential fatty acids, known as
immunonutrients. They reduce the severity of illness and improve response to treatment of patients. Nutrition support specialists are trying to
improve the management protocols and technological advances such as nanotechnology and biomarkers will take the nutrition management to
greater advances.
Keywords: Assessment, biomarkers, hypermetabolism, parenteral nutrition, pediatric burn nutrition, micronutrient, nanotechnology,
substrates
INTRODUCTION better antibiotics, nanotechnology-based dressing materials,

and nutritional support. Developments in anesthesia
In India, over an estimated 1,000,000 people sustain
techniques, advances in surgical modalities, and intensive
moderate-to-severe burn injuries every year. Annually, 7
burn care therapies have resulted in reduction of both
million people with burn injuries require hospital
mortality and in postburn sequelae. National Programme
admission of which 140,000 are fatal. The National Burns
for Prevention and Management of Burn Injuries
Program statistics show that 91,000 women sustain burn
(NPPMBI) guidelines lay more emphasis on prevention of
injuries. Children and women of child-bearing age are more
burn injuries. World Health Organization (WHO) has an
likely to sustain burn injuries and mortality is 3 times more
estimated 180,000 deaths caused by burn injuries.
compared to men.[1] Critically, ill burn patients pose a great
Developing low- and middle-income countries contribute
treatment challenge to the attending intensivist. Burn injuries
of minor nature can be treated on an outpatient basis. Less
than 10% of the victims require hospitalization, and the Address for correspondence: Dr. Mariappan Natarajan, Associate Professor
of Hand Surgery, Department of Hand Surgery, Sri Ramachandra Institute of
proportion of patients requiring treatment in burn intensive Higher Education and Research, Porur, Chennai-600116. 9901043568;
care units (BICU) is less. During the last three decades, the E-mail: drn_m@hotmail.com
burn care has improved tremendously with the availability of
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DOI: How to cite this article: Natarajan M. Recent Concepts in Nutritional

10.4103/ijnpnd.ijnpnd_58_18 Therapy in Critically Ill Burn Patients. Int J Nutr Pharmacol Neurol Dis
2019;9:4-36.
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Natarajan: Nutrition in critically ill burn patients
to nearly 95% of fatal fire-related burn injuries according to corrosive substance onto the body of another “with the
WHO fact sheet, 2018. Emphasis must focus on prevention of intention to disfigure, maim, torture, or kill.” Acid attack
burn injuries, nutritional care, and rehabilitation.[2] is “crime of passion” as a result of jealousy or revenge, with
International Society for Burn Injuries (ISBI) and intent to burn and damage skin of faces to cause permanent
European Burn Association (EBA) are the major disfigurement. Sulfuric and nitric acids are the most
organizations in the field of burn injuries and research. commonly used acids. Hydrochloric acid is sometimes
Patients with major burns are considered as critically ill, used, but is less damaging to tissues. Strong alkaline
and protocols of general intensive care units (ICU) care solutions of caustic soda (sodium hydroxide) are also used.
recommendations apply to such patients. Randomized and Acid attacks happen all over the world, but this type of
placebo-controlled human studies of high quality with large violence is most common in South Asia. According to
number of patients on major burn-specific issues have been Acid Survivors Trust International (ASTI), the UK has one
investigated.[3] GRADE rating in healthcare is a method of of the highest rates of acid attacks per capita in the world. In
assessing the certainty in evidence and the strength of 2016 there were more than 601 acid attacks in the UK based
recommendations [Table 1]. on ASTI figures. In India accurate statistics of chemical burn
injuries are not available as many incidents go unreported for
Nutritional supplementation is crucial in critically ill burn
fear of retaliation. Acid Survivors Foundation India (ASFI)
patient treatment protocols. Guidelines and protocols of
statistics show a clear increase in number of acid attacks
nutritional therapy in critically sick persons in ICU are
every year with around 1000. Immediate first aid of chemical
extended to the nutritional management of burn patients
burn injuries include:
also.[4] The challenges are more in patients with associated
Inform emergency medical services and poison control
trauma, comorbidities, and complications such as inhalation
center
injuries. The gross pathophysiological changes, altered fluid
Try to remove the chemical and contaminated clothing
dynamics, metabolic, and electrolyte derangements are the
carefully, with all personal protection precautions
challenges in management. In addition, infectious
Rinse the affected area with running clean water for 20
complications and the severity of burns largely influence the
min
nutritional parameters and therapeutic interventions. Emerging
Some acid burns may be made worse if rinsed (flushed)
trends are supported by the evolution of critical care services
with water, namely, carbolic acid or phenol, sulphuric
and evidence-based medical care protocols are supported by the
acid, and metal compounds
emerging technological advances. This manuscript is aimed at
Flush with large amounts of water to remove chemical
discussing the important issues pertaining to the nutritional
from the eyes, to reduce chances of serious injury to the
supplementation of patients with critical burn injuries and the
eyes
recent technological advances in the field of nutrition sciences.
Chemical burn injuries occur in accidentally at chemical Pathophysiology: Most acids produce coagulation necrosis
industries and at home. It is a sensitive social issue and needs by denaturing proteins. The eschar formed prevents tissue
a special mention. The most important cause of chemical penetration of acids. Bases produce liquefaction necrosis by
injury is acid attack. Acid throwing (vitriolage) is a form of denaturing proteins and, in addition, cause saponification of
violent assault defined as the act of throwing acid or similar fats. This does not prevent tissue penetration and the tissue
Table 1: Grade of recommendation, assessment, development, and evaluation

Topic Grade Agreement
Indication Initiate nutrition within 12 h by enteral route B Strong
Route Enteral method is preferred and parenteral is rarely indicated C Strong
Energy needs/equations Gold standard is indirect calorimetry. For adults Toronto equation and for children Schofield D Weak
for calculation equations are alternatives, if IC is not available
Proteins Adults protein needs 1.5–2.0 g/kg; children need 1.5–3 g/kg/day. They are higher than in critical D Strong
patients due to other conditions
Glutamine or ornithine alpha-ketoglutarate is ideal and arginine is not advised C Weak
Glucose levels and Carbohydrate sources make up for 60% of total energy intake (limit to below 5 mg/kg/min in D Strong
glycemic control adults and children)
Continuous intravenous infusion of insulin keeps glucose levels under 8 mmol/L (and over D Strong
4.5 mmol/L)
Lipids Fat energy sources form <35% of total energy and monitor total fat delivery C Weak
Micronutrients Adults and children need zinc, copper, and selenium; vitamin B1, C, D, and E C Strong
Metabolic modulation Warm ambient temperature, early excision/grafting, nonselective beta-blockers, and oxandrolone B Strong
are the nonnutritional strategies to attenuate hypermetabolism and hypercatabolism in both adults
and children
rhGH is recommended for children with burn of >60% TBSA B Weak
International Journal of Nutrition, Pharmacology, Neurological Diseases ¦ Volume 9 ¦ Issue 1 ¦ January-March 2019 5
damage is more. Hydrofluoric acid produces liquefaction organs. The liver, heart, gastrointestinal tract, muscle,
necrosis. The severity of burn depends on the pH of the bone, and kidneys are the common organs affected.
chemical, concentration, duration of contact, volume, and Altered metabolic functions mediated by a sharp rise in
physical form of the chemical. The amount of thermal and the serum levels of catecholamine, corticosteroids, and
caustic injury caused by dilution also plays an important role inflammatory cytokines persist for more than 2–3 years
in tissue destruction. There may be an associated ingestion of following severe burn injury. Hypercatabolism is
chemicals. characteristized by the following features in a patient
with 25% burns: (1) metabolic rate in an adult patient is
EMERGENCY DEPARTMENT CARE OF PATIENTS elevated to as high as 118%–210%. (2) Approximately
180% rise in resting metabolic rate. (3) Calorie need
Complete removal of the chemical contamination with exceeds 5000 kcal/day. (4) The patient with 40% burn
continued low pressure irrigation injury loses 25% of preadmission weight within 3 weeks
Measure pH using litmus paper time without nutritional support. (5) Impaired immunity
Secure airway and fluid resuscitation are started and delayed wound healing. The stress response has an
initial hypometabolic “ebb” phase (lasts from days to
Treatment is continued as for a typical burn injury patient and
weeks) followed by hypermetabolic “flow” phase
wounds must be covered as early as possible as per the burn unit
beginning at about the fifth postburn day and may
protocols. Hydrofluoric acid burn needs special mention as the
persist up to 24 months.[6] Lean body mass reduction,
fluoride ion penetrates through the skin. For small and superficial
bone density alterations, and weakness of the muscles of
burns, topical calcium or magnesium gels are applied. For deeper
stress response affect immune function and wound healing
burns, injection of calcium gluconate is used. For burns involving
[Figure 1]. Burn injury has the highest metabolic response
the hands, subcutaneous injection of calcium, intra-arterial
among critically ill trauma patients. Damaged tissues
calcium infusions, or intravenous infusions of magnesium are
activate the inflammatory event that maintains the
used. Consultations: Ophthalmologist consultation is a must for
catabolic state. The high circulating levels of cytokines
all chemical burns involving face. For suspected ingestion of
modify the basal metabolism of the body and keep it at a
chemicals, gastroenterologist, GI surgery, and ENT surgeon
higher level for long periods after acute trauma.[7]
opinions must be followed. Children require management by
a pediatric surgeon. As the resting energy expenditure (REE) reaches more than
10% above normal, the patient is in a hypermetabolic state.
Chemical burn injuries have devastating effect on the social,
There is an increased consumption of whole-body oxygen.
economic, psychological, and morale of the affected person.
REE remains high between 40% and 100% above normal in
Repeated reconstructive surgical procedures may be required.
acute postburn phase with greater than 40% total body surface
A long period of rehabilitation and psychological counseling
area (TBSA) burn. Surgical and nonsurgical treatments
are needed for the victims. Support from the family,
implemented by the burn team effectively control the
governmental, and nongovernmental organizations are
stress response. Wound excision and early skin cover is
crucial in recovery of such unfortunate victims.
the most beneficial surgical modality. Nonsurgical methods
Governmental legislations and education of general public
available are adequate analgesia, administration of
will help in minimizing acid attacks in future.
catecholamine antagonists, and anabolic hormone
pharmacological therapy. Provision of adequate and early
SOCIOECONOMIC ASPECTS OF SEVERE BURN INJURIES nutritional support is an important factor that determines the
Management of burn injury is resource and time-intensive. positive outcome in patients. Enteral nutrition (EN) support
Most patients require a long duration of hospital stay, and
significant costs are involved. The socioeconomic burden of
burn injury is very high. Medical expenses are a huge burden,
and the personal and per capita income of the family is reduced
significantly depending on severity of injury.[5] Management of
burn injuries involves huge part of the exchequer on part of the
governments. This financial burden on the government is
beyond the monetary budget of developing nations such as
India. Corporate social responsibility, involvement of social
service organizations, nongovernment organizations, and
formation of burn patients support groups will be beneficial
to the patients with burn injury.
HYPERMETABOLIC STATE IN BURN INJURIES

Severe burn injury elicits physiologic response not only at Figure 1: Hypermetabolic response is associated with severe burn
the site of injury, but also alters the functions of various injuries, trauma, and sepsis
6 International Journal of Nutrition, Pharmacology, Neurological Diseases ¦ Volume 9 ¦ Issue 1 ¦ January-March 2019
with adequate protein, carbohydrate, antioxidants, vitamins, (3) IL-6 stimulates release of C-reactive protein (CRP) and
minerals, and trace elements is essential for reverting the procalcitonin.
effects hypermetabolic changes. (4) Infection releases more tumor necrosis factor-alpha
(TNF-a) that stimulates more production of IL-6 and
Hypermetabolic response during postburn injury is mediated
IL-8 that are responsible for high fever of infection.
by cytokine cascade, catecholamine, and corticosteroids. The
(5) A shift from Th1 to Th2 cytokine response leads to an
circulating serum levels are elevated by 10–20 times more in
increase in Th2 antibody-mediated (humoral) immune
the postburn period and remain high for up to 12 months
responses.
following burn injury.[8] Elevated catabolic hormones result
(6) High mobility group box 1 (HMGB1) released
in insulin resistance, increased gluconeogenesis, energy
passively by damaged cells results in SIRS.
consumption, lipolysis, and proteolysis. Gluconeogenesis-
(7) Inflammatory cascade amplification.[10]
mediated high serum glucose level is not “protein
sparing.” They may lead to poor “take” of graft, increased In SIRS, shift of vitamins and trace elements from circulation
incidence of wound infection, morbidity, and mortality. The into tissues and organs occurs. They are utilized to enhance
catastrophic metabolic changes have to be taken care of for protein synthesis and production of immune cells. Trace
better outcome of the patients. Pathophysiology of burn elements, antioxidants, and water soluble vitamins are also
injuries is dynamically changing and complex. Nutrition used up in this process and are deficient. Antioxidants,
and metabolism in burn patients are difficult to assess and vitamins, and trace element supplementation help to
treat during burn care. Different compositions of nutrition are modulate this response.
required at different stages of the course of treatment.
Variations in treatment methods and complex Concerns in critically ill burn patients: A multidisciplinary
pathophysiology of individual response patients are the approach is needed for management of burn patients. The
important factors. It may take long to standardize challenges are:
nutritional plan program in a burn center. Multi- (1) the gross altered pathophysiologic changes,
institutional trials are difficult to implement because of (2) altered fluid dynamics,
differing nutritional support requirements in different (3) vulnerability to infections,
individuals, and an optimal nutrition protocol has to be (4) metabolic derangements,
individual-based one. Physiological/biochemical markers (5) electrolyte disturbances, and
are useful to assess potential benefits of nutrients, and (6) influence of severity of burns on the nutritional
evidence-based clinical trials will be beneficial in future. parameters and therapeutic interventions.
Management of critically ill burn patients is extremely
Pathophysiology of altered metabolic state: Hyperdynamic
challenging to the attending burn care team. The
circulatory state is seen with burn injuries greater than 40%
catastrophic effects of prolonged hypercatabolism needs to
TBSA. Increased levels of catecholamines, glucocorticoids,
be managed:
glucagon, and dopamine lead to catabolic state [Figure 2].
(1) Hypercatabolism leads to fatal cachexia with a weight
There is massive protein and lipid breakdown resulting in
loss of up to 40% of admission weight and increased
muscle wasting. Hyperglycemia occurs due to peripheral
rates of bone catabolism
insulin resistance. The altered metabolic state begins
(2) Immunosuppression
within days of burn, which may persist for several years
(3) Children develop growth retardation, which may persist
postburn. Associated inhalational injury leads to airway
up to 1 year postinjury[9]
edema, fluid and electrolyte imbalances, thermoregulatory
(4) Lean body mass loss of 10% leads to immune
changes, and increased risk for infections. Ventilatory drive is
dysfunction and loss of 20% leads to significant
decreased due to weakness of respiratory muscles. This leads
impairment of wound healing
to more ventilatory support days and increased hospital stay.
Critical illness “stress response” to severe burn continues Various nutrients and drugs have impact on the reversal of the
for a few years following injury. The pathophysiology of hypermetabolic state. Nutrition supplies important cell substrates
stress response is complex and difficult to contain. The WBC and vital nutrients required for body metabolism. Morbidity and
genome of burn patients remained changed for up to 1 year mortality increase as severe burn injury affects functions of other
postburn. Burn-induced hypermetabolism is characterized by organs of the body. Early wound excision and skin cover is the
increased substrate turnover, cachexia, and poor clinical key to reduce the mortality and morbidity. High protein and
outcomes. Oxidative stress and systemic inflammatory nutrient supplementation on an aggressive nutritional support
response syndrome (SIRS) are characterized by: basis is required in patients with burn injuries:
(1) Formation of free radical. elevated metabolic demands need to be meet,
(2) Cleavage of the nuclear factor kappa B (NF-B) prevention of energy reserves and nitrogen stores depletion,
inhibitor. When the inhibitor is removed, NF-B to support good healing of wound,
initiates mRNA, which induces production of other to boost immunity, and
pro-inflammatory cytokines. to improve survival rate of critically ill burn patients.[11]
Figure 2: Effect of burn wound on functions of various organs
Important aspects in burn patients: Inhalation injury syndrome causes morbidity and mortality as direct effects of
adds insult to the injury and patients may need respiratory complications. Inspite of recent advances in early care of burn
assistance of lung protective mechanical ventilation similar to patients, these complications still remain a challenge.
acute respiratory distress syndrome (ARDS).[12] Damage to Immune modulator treatment protocols may reduce these
upper airway and presence of inhalation injury requires a high complications, and it may be possible in near future to
degree of suspicion to identify even in the absence of overcome the challenges.
detectable oropharyngeal changes.[13] The levels of
Pain management and sedation: Goal of burn care is
combustion products such as carbon monoxide or cyanide
adequate pain relief and priority must be given for pain
in the blood may be elevated. Bronchoscopy demonstrates
relief along with other resuscitation measures. The severity of
anatomic injury and is the “gold standard” for diagnosis.
pain depends on the depth and total area of burn. The
Increased fluid requirements are associated with inhalation
psychological trauma is associated with the frequency, the
injury and fluid allowances are added accordingly. Heparin
need for multiple procedures, and the fear of future. The
inhalation has been identified to be effective in treatment of
cornerstone of critical burn care of today is the high-quality
inhalation injuries. Dimethyl sulfoxide or N-acetylcysteine
analgesia and sedation along with resuscitation.[17,18] Burn
are free-radical scavenging agents with beneficial effects
patients require sedation and analgesia very frequently and
along with bronchodilators in treatment of inhalation
have an increased risk of constipation. Diet rich in fiber
injury.[14] The primary aim of therapy is to prevent cast
content can avoid constipation.
formation that may lead to small-airway obstruction.[15]
Lung injury in burn patients leads to ARDS due to Burn injury in obese patients: Obesity is considered a state
reduced ventilation perfusion. Nitric oxide dilates blood of chronic inflammation.
vessels, increases perfusion of lung alveoli, and corrects
Pro-inflammatory cytokines, including IL-6, TNF-a, and
the ventilation-perfusion mismatch.
CRP levels, are high in obese patients. They are more
Immunological response to burn injury: Infectious susceptible to the increased inflammation and associated
complications are significantly raised because of hypermetabolism. There is severe and rapid muscle
immunosuppression in burn patients. “Burn toxins” are wasting in the early postburn period. There is also severe
associated with prolonged allograft survival and anergy insulin resistance in obese patients. Decreased bioavailability
that make burn patients more susceptibile to infections.[16] of vitamin D3 in burn patients may lead to vitamin D and
Patients develop SIRS and sepsis. Multiple organ dysfunction calcium deficiency in such patients.
Wound healing in burn patients: Glucose is the preferred (1) Burn injuries greater than 30% TBSA.
energy substrate for macrophages, leucocytes, and fibroblasts (2) Extremes of age: Younger and older age groups of
in the burn wound. Wound-generated lactate is converted patients are more susceptible to complications of
back to glucose the liver. An increase in cori cycle has the burn injuries.
advantage of energy production. Alteration in systemic pH (3) Burn injuries associated with smoke inhalation.
due to lactate has bacteriostatic effect and stimulates collagen (4) Burn injuries associated with high-voltage electric
synthesis, which is beneficial for wound healing. Lactate current.
induces collagen synthesis, vascular endothelial growth (5) Burns patients with comorbid illness/conditions.
factor (VEGF) expression, and migration in endothelial
cells through generation of superoxide. Plasma lactate is a Treatment of critically ill patients of any cause is a great
good predictor marker of sepsis and mortality in burn challenge. Severity of illness with unpredicted metabolic and
patients. A serum level of 4 mmol/L provides the best physiological changes makes the treatment complex and
sensitivity and specificity. Mortality in burns can be sophisticated. The general principles of management of
reduced by fluid resuscitation that normalizes plasma critically ill patients include:
lactate levels, and it is a reliable prognostic marker of Early and adequate resuscitation to maintain an optimal blood
global tissue hypoxia. Exogenous glucose administration volume is the priority. An adequate circulatory state must be
diminishes endogenous production by only about 50%. maintained on a continuous process.
Burn patients have increased glucagon: insulin ratio and Management of respiratory impairment and circulatory
insulin resistance. Hyperglycemia associated with burns derangements are crucial for patient survival.
results in delayed healing, depressed immune activities, Prevention of sepsis and treatment of infectious
and exacerbation of protein catabolism. complications are important.
Increased mortality is due to rapid development of
Nutritional support of elderly burn patients: Elderly malnutrition. Hence, early metabolic support is
patients with extensive burn injuries are more susceptible essential.[20] Wound healing and tissue repair depend on
to pronounced metabolic response. Nutritional support is an adequate enteral nutrition.
required for balancing the enhanced energy expenditure Renal support with renal replacement therapy may be
and for survival of the patient. The acutely injured elderly required in some patients. An extracorporeal continuous
patients must be supplemented with early, internal continuous venovenous hemodiafiltration (CVVHDF) method is ideal.
nutritional support through nasogastric tube (NGT) for Psychosocial support for both the patient and their family help
providing the extensive calorie requirements. This in early rehabilitation of burn victims. Adequate analgesia,
effectively prevents upper gastrointestinal tract ulcer treatment of anxiety, comfort, and dignity help in both the
formation and stress hemorrhage in the elderly patients recovery and rehabilitation phases of burn injuries. The
and reduces frequency of complications related to sepsis. family needs access to information and support so that
Basal energy expenditure (BEE) with incremental energy they can take care of the victims.
input is calculated based on body weight, and burn size is Advantages of intensive care units include the presence of a
used to calculate nutritional requirement in the elderly patient highly skilled multidisciplinary team and specialized
with burn injuries. In the elderly population, it is important to environment to identify problems and institute early,
assess preexisting protein-energy malnutrition and look for necessary treatment options.
the presence of involuntary weight loss. Increased incidence
of infections, poor healing properties, and mortality are the The critical burn injury patients pose special additional
complications in such patients. Preexisting micronutrient challenges when compared with critical ill patients due to
deficiency states are also common in elderly patients and other causes. The unique challenges in critically ill burn
replacement therapy must be considered. patients are spread over a spectrum of variables. Pattern of
Criteria for critical burn injury: Infection and sepsis are complications is unpredictable with variable determinants of
still the biggest threats to survival from burn injuries outcome. Resuscitation requirements and severe metabolic
especially in the developing countries. Burn wound sepsis stress of burn injuries need to be addressed on priority basis.
and nosocomial pneumonia, including ventilator-associated Hence, treatment modalities greatly differ from the
pneumonia (VAP), are the common causes of mortality. management of critical patients of other causes. Early
Reactive oxygen species (ROS) are natural by-product of diagnosis of problems and immediate institution of specific
normal oxygen metabolism and play an important role in cell therapy are required to minimize the mortality and morbidity.
signaling and homeostasis. They have positive physiologic,
metabolic, and immune changes in association with medical Initial phase of fluid resuscitation: The Parkland formula
and nutrition therapy. Severe burns with fluid depletion, has the advantages of being simple and easy to initiate and
hemodynamic instability, airway problems, and patients ideal for fluid therapy in the initial critical stage of
requiring pain management are best treated in critical care resuscitation. The disadvantages of Parkland formula are
units. Zaidi et al. in 1996 formulated the following criteria for that it is a high-volume resuscitation formula and patients
admission to BICU:[19] receive greater fluid volume than predicted. A “Protocolized”
Parkland formula was formulated due to doubts regarding methodology of nutritional maintenance in critically ill
accuracy and practicality of the formula. Initial fluid patients has given way to a more pragmatic and restricted
requirements, rate of administration, and hourly infusions feed concept, guided by principles of evidence-based
are started as per Parkland formula. The fluids are adjusted pritocols.
according to the patient’s response and hourly urine output Enteral nutrition is used whenever possible and is the most
measurements. The protocol can be initiated by a highly preferred route.
trained specialized nursing personnel. Inadequate response If the gut is malfunctioning, parenteral nutrition is the choice
to fluids, persistently high fluid requirements, and unstable for nutritional supplementation.
vital signs in the patients during resuscitation need the Nutrition therapy reduces or blunt the effects of
intervention of the physician. Patients with symptoms of hypercatabolic state, which is a unique feature in critically
compartment syndrome and with increasing fluid ill patients.
requirements are modified to colloid replacement as per The caloric balance is maintained with 1500–2100 cal/day
the “American Burn Association practice guidelines” for instead of the routinely practiced concept of providing
burn shock resuscitation. This Parkland Consensus excessive calories intake up to 3500–4500 cal/day.
formula for resuscitation calculates Ringer lactate solution Early nutrition must be started as “proactive approach” in
for the first 24 h and is widely used by many burn centers at preventing starvation rather than treating it later on.
present: 4 mL/kg/% TBSA burned (“kg” is initial weight of Nutrition should be personalized for each patient taking into
the patient; “% TBSA” is the total of second and third degree consideration the stage of burn care and condition of the
burn injury). Half of the calculated fluid for 24 h is infused in wounds. Specific surgical and medical needs of the patient
the first 8 h. The remaining half is given over the next 16 h. and current nutritional status of the patient must always be
The general guidelines for fluid resuscitation are as follows: taken into consideration.[21]
Oral fluid resuscitation is sufficient for patients with burns Reassess adequacy of nutritional support for the patient and
<20% TBSA. Patients with normal gastrointestinal tract can check for possible side effects on time-to-time basis.
tolerate large amounts of fluid. The patient must be under
close observation and enteral resuscitation should be initiated
Mortality prognostic scales in severe burns: Patients with
as and when is necessary.
critical burn injury have increased chances of survival due to the
Patients with associated comorbidities are ideally under
advances in development of intensive care management
invasive central hemodynamic monitoring, such as central
protocols. It has changed the understanding and concept of
venous catheters and pulmonary artery catheters. In patients
burn shock. Main factors that determine treatment outcome are
with central monitors fluid administered and corresponding
the presence or absence of inhalation injury, preexisting
improvement in outcome do not correlate well. The treating
malnutrition, acute renal failure, concomitant injuries and
team must be aware of the fact.
diseases, the presence of infection, and psychiatric
Antioxidant therapy helps to reduce burn resuscitation fluid
disorders.[22] Patients with extensive burns require
requirements and prevent formation of edema.
multidisciplinary and multidirectional treatment. Multi-organ
“Fluid creep” is the most important problem during the initial
failure causes death in approximately 28% of burn patients.
phase of fluid resuscitation. Fluid creep is the requirement of
Acute Physiology and Chronic Health Evaluation II and sepsis-
more fluid than calculated by standard formulas and has
related organ failure assessment score are extensively used
serious edema-related complications. It may be due to lack
prognostic methods in critical care units.[23,24]
or failure to add colloids in the resuscitation fluids used.
Burns evaluation and mortality (the BEAMS prognostic
score) is modified from APACHE II scale. The BEAMS
Fluid resuscitation has been improved with an incorporated
computerized decision support system for patients with risk of death is an outcome tool for prediction for adult major
burn injury patients admitted to ICU. It is an accurate and
severe burn injuries: A fluid resuscitation pump along
reliable mortality prediction tool. Burns-specific physiologic
with a urine analysis monitor has been designed with a
pulse oximeter, and a blood pressure monitor incorporated factors such as age and percentage of full thickness surface
area of burn (%FTSA) are the main factors considered.
into a closed-loop medical device hardware platform. When
Female sex and APACHE II are independent predictors of
connected to a ventilator, it optimizes fluid therapy. It records
and communicates resuscitation data. This system calculates death among burn patients. A combination of Fatality by
Longevity, Apache II score, and Measured Extent of Burn
fluid therapy parameters and minimizes automation of
score (FLAME) is reliable predictive scale based on the
caregiver tasks. It is simple enough to be operated by a
minimally trained medic. The computer monitors the APACHE II.[25] Simplified acute physiology score (SAPS)
is specific and accurate particularly in burns <40% TBSA.[26]
patient on a minute-by-minute basis with less chance for
During the first 10 days the presence or absence of inhalation
errors and complications due to under-resuscitation or fluid
overload. injury, extremes of age, and extent of burn injury are the main
predictors of mortality. The other significant predictors (P <
Principles of nutrition management in critically ill burn 0.05) include absolute monocytes count, lymphocyte count,
patient: The concept of hyperalimentation as the maximum daily temperature (Tmax), and BUN.
Baux rule is a simple calculation in patients suffering from Teamwork is a crucial component in patient care of a major
second and third degree burns.[27] Baux score is expressed as: burn injury. The integral components in all areas of patient
Baux score = % burn area + patient’s age. A score over 140 is management consists of patient education and treatment
considered as being unsurvivable. Revised Baux scale planning. Management of complications, control of
includes the presence of inhalation injury and is more infection, occupational health, and safety must be ensured
promising as a prognostic marker in burn survival. as teamwork. Psychosocial care of patients and the families
Inhalation injury adds 17 points on the Baux score. and continuous professional development are essential for
Revised Baux scale = body area affected + age + 17. final outcome of burn injury patients.
Platelets play a significant primary and secondary hemostasis
The burn team includes the following members:
mechanism and also act as inflammatory cells. A significant
Anesthetists/pain management specialists, medical specialists,
low platelet level is noted in nonsurvivors of burn injury than
and intensivists are vital team members. Child life specialists/
in survivors. A rebound rise in platelets occurs in survivors in
play therapists take part in management of children. Dietitians
subsequent postburn days. Serial declining platelet count is a
and diet technicians along with nutritionists and nutrition
prognostic indicator of early burn septicemia, which indicates
assistants are responsible for diet and nutritional aspects in
the need to modify treatment modalities. Correlating survival
burn patients. Nursing staff and indigenous health workers
versus platelet aggregation against survival versus the revised
carry out the needs of the patients. Oral health specialists and
Baux score is a prognostic indicator for survival following
dental health technicians are essential for maintaining the oral
major burn injuries. Updated Charlson comorbidity index
health. Occupational therapist, orthotists/prosthetists,
(CCI) is another prognostic study in relation to inpatient
physiotherapists, psychiatrists, psychologists, and mental
mortality.
health workers help in rehabilitation process of the patients.
Clinical effects of malnutrition in burn patients are varied Social workers, pharmacists, rehabilitation specialists, and
with drastic effect on the overall physiological and clinical speech and language pathologist play a key role in patient
status of critically ill patients. They have specific and care. Parents and family caregivers have a well-defined role
nonspecific effects on the health of the patient. in final outcome of the patient care. Recently, many American
hospitals have included palliative care specialists in the
A. Specific effects [Table 2] of malnutrition include poor
healthcare team. Integration of primary and specialist
healing, wound dehiscence, breakdown of surgical
palliative care in burn critical care program has potential
anastomosis, poor immune response to infection, and
benefits for the patient and their families.
failure of skin grafts.
B. Nonspecific effects: Nutrient requirements in critical burn patients are
(1) Lean muscle mass: Neoglucogenesis leads to markedly increased. Following major burn injuries,
substantial loss of muscle mass that leads to nutrient stores get repleted quickly and it affects various
increased work of breathing. Such patients develop physiological and metabolic functions of the body.
ventilator dependence, a challenging clinical situation Patients with greater than 20% TBSA burn and patients in
to manage. acute stress response should receive nutritional support
(2) Sepsis: Nutritional deprivation in the setting of sepsis Patients with lesser percentage of burn wounds but with
can lead to multi-organ dysfunction syndrome. The liver preexisting malnutrition are candidates for nutritional support
and kidney are the most affected organs. Patients with tuberculosis or HIV/AIDS need close
(3) Central nervous system is affected due to alteration in monitoring and nutritional support must be added as and
amino acid composition as a result of nutritional when required
deprivation. Apathy, drowsiness, and inability to
clear secretions are the common presentations. Factors that influence nutritional requirements in burn injury
patients are as follows:
Age: Children, elderly, and teenagers are most vulnerable
to the effects of burn injuries
Table 2: Wound healing has three phases Pregnant and lactating women with burn injuries pose a
challenge for nutritional support
Phase Characteristics Key players
Nutritional status of the individual before the burn injury
Inflammatory Vasodilation, Extravasation of fluid Neutrophils Diseases such as tuberculosis, HIV/AIDS, diabetes
and edema mellitus, and stress diabetes
Monocytes Renal failure and associated electrolyte disturbances
Macrophages
Infection, sepsis, and associated fever
Proliferative Closure of wound and revascularization Keratinocytes
Excessive humidity and environmental temperature
Fibroblasts
changes
Remodeling Maturation of wound and scarring Collagen
Pain and anxiety increase in metabolic rate and they must
Elastin
be controlled effectively
“The art of clinical management” is an estimation of nutrient Nutritional assessment in adult burn patients: Initial
requirements and assessment of nutritional status of burn assessment of all patients with critical burn injuries is
injury patients. Monitoring the response to feeding should mandatory to form a baseline data for knowing the
also be done regularly and adequately. This requires the progress made throughout the therapy. Initial nutrition
integration of science and various medical specialities for assessment should be made on admission to hospital and
maximal benefit for the patient. feeding must be initiated within the first 24–48 h of burn
injury. Nutritional evaluation must be taken into
consideration:
GOALS OF NUTRITIONAL SUPPORT IN CRITICAL BURN Height and preburn weight of the patient are noted.
Administration of fluid and edema alter the weight
PATIENTS INCLUDE:
measurements
Lean body mass must be maintained Preburn nutrition history and current functional status of
Prevent starvation and avoid establishment of specific gastrointestinal tract
nutrient deficiencies Percentage of body surface of burn injury: sites of injury
Hasten good wound healing (around oral cavity and hands)
Prevention, control of infections, and management of Type and the level of pain control measures used
established infections Comorbid conditions or illness
Visceral and somatic protein loss must be restored Usual diet of the patient, specific dietary needs, and
Enteral and parenteral nutrition-related complications must associated food allergies
be prevented
Stress response and complications must be attenuated or Identification of nutrition risk patients: Nutrition status is
modulated with adequate and appropriate quantities of an ongoing dynamic process. The nutritional status in burn
required nutrients[28] patients depends on the stage of injury and the treatment
protocols. Malnourished patients have greatest risk for
The nutrition plan must be coordinated from the time of refeeding syndrome on initiation of nutrition support.
admission to scar maturation based on the treatment and Patients on nutritional rehabilitation before surgical
requirements at different stages. Consensus approach with treatment and prior to discharge have better final outcome
other team members is ideal through consultations. The results. Initial evaluation includes history related to number
dietitian should implement nutrition plan with consideration for: of postburn days, details of previous burn care, associated
Age, gender, and level of alertness of the patient injuries, comorbid conditions, height, weight, and clinical
Location and the status of wounds and skin replacement plans examination assessment of patients. Nutritional risk factors
Physical status and preexisting nutritional status prior to include:
injury Preexisting nutritional status
Functional status of the gastrointestinal tract Identify factors wherein the patient is not able to receive
Lung function status and respiratory needs nutritions or not able to utilize nutrients he receives during
Pyrexia due to infections and other causes stay in the hospital
Pain management and sedation protocols followed in the Age of the patient, severity of burn injury, associated
particular unit inhalation injury, or organ dysfunction
Support of family and friends and psychosocial status of the
patient Timing of nutritional support: Institution of early burn
care treatment including nutritional support is crucial for
patient outcome following severe burn injury. Ideally, EN
Individual patient factors are crucial for final outcome in initiated within 24 h of burn injury prevents development
patients following burn injury management. Compliance of malnutrition and depletion of nutrients. Following burn
and individual priorities, cultural background, and injury, there is increased bacterial translocation and
religious beliefs are the key for optimal recovery. decreased absorption of nutrients and lead to
Preinjury behavioral problems, history of psychiatric or substantial intestinal mucosal damage. Early EN has
psychological illness, learning disabilities, or distinct advantages and prevents the gastrointestinal
developmental delay has a profound effect on the final complications.
outcome. Reconstructive surgery-related psychological Catecholamine, cortisol, and glucagon circulating levels
changes and previous experiences of hospitalization decrease
have a great role in the final outcome. Parents, Intestinal mucosal integrity is maintained as gut motility and
caregivers, and family members responses alter the blood flow are optimized and prevent development of
course of the therapy, and every effort must be taken to curling’s ulcer
educate them throughout the treatment and rehabilitation Improves wound healing. Muscle mass is maintained
process. Special dietary needs and food allergies need Duration of stay in intensive care unit is made much shorter
attention for better results. with nutritional support[29]
Feeding through enteral route is started as continuous and Initial estimation of caloric needs is by using weight of the
low-volume feed and slowly increased to attain the goal patient when BMI is 30 kg/m2 (Class 1 obesity). If BMI is
volume. This makes sure the patient tolerates the regimen >30 kg/m2, adjusted body weight is used for estimation. The
and that it can be continued. Parenteral and enteral route ultimate goal is to minimize weight loss. Caloric need
feedings are always given on a continuous basis. Nutritional estimates are done using the following equations at the
requirements can be met with by many methods: time of admission:
Diet rich in protein and calorie content (includes oral nutrition Zawacki: Resting metabolic rate (RMR (kcal/
supplements) day) = 1440 × BSA (m2).
Diet with high protein and high calorie, supplemented with Xie: RMR (kcal/day) = (1000/BSA [m2]) + (25 × BSAB [m2]).
enteral feeding
Feeding through enteral route Curreri formula (1972) calculates the approximate calories
Parenteral nutrition required to compensate for the patient’s weight loss. Many
older formulas tend to overestimate current metabolic
requirements. Energy expenditure fluctuates following
GENERAL GUIDELINES FOR NUTRITIONAL ASSESSMENT,
burn injury. Fixed formulas have the disadvantage of a
INTERVENTION, AND INDICATIONS FOR NUTRITIONAL tendency to underfeeding at times of highest energy
THERAPY ARE AS FOLLOWS: utilization. They lead to overfeeding late in the course of
Adults with <15%–20% TBSA burn injury will be able to get treatment. Recent formulas use different variables in the
adequate nutrition through oral route. Adults with >15% calculation and are more accurate.
TBSA burn injury and children with >10% burn injuries Underfeeding is common with fixed weight-based equations
require nutritional support.[30] used in ICU for calculating nutritional needs. Stress factors
Patients affected with greater than 20% burn injury and/or used in Harris–Benedict equation are also unreliable. Fatty
inhalation injuries need close observation and may require liver infiltration of overfeeding results in increased infection-
enteral feeding. Patients on therapeutic diets and those with related complications. Hildreth and Galveston equation
poor nutrition status on admission are candidates for carries the same risk of overfeeding in children. Hence,
additional nutritional support. indirect calorimetry is considered as the gold standard
Inadequate dietary intake of in postadmission period due to for estimation of energy requirements in adults and
facial or hand burns. children. Toronto equation, based on multiple regression
Early enteral feeding preferred for its gastrointestinal benefits analysis of calorimetric studies, is a good alternative.
in burn injury patients. Estimation of energy needs is a challenging task in the
Nasojejunal feeding is considered if nasogastric feeding is absence of calorimetry. In such situations, Xie et al. and
unsuccessful. Milner et al. methods are useful.[32,33] Xie et al. formula:
Second choice for nutritional support is total parenteral Energy expenditure (kcal/d) = (1000 kcal × BSA
nutrition (TPN). It effectively corrects the undernutrition [m2]) + (25 × %BSAB)[34] (BSA—body surface area:
and insufficient energy intake. The disadvantages include BSAB—percentage of TBSA burn).
infection of central venous access and sepsis with increased
Harris–Benedict equation is most commonly used for
mortality in severely burned patients.
estimation of caloric needs. Total energy expenditure
(TEE) has three components, namely, BEE, voluntary
Factors affecting intake of diets: Anorexia, nausea, or
activity, and thermal effect of food. Gender, age, weight,
vomiting prevents the patient from taking adequate
and height of the patient are used to calculate the estimated
nutrition orally. Pain of wound and procedures such as
BEE using this equation. Harris–Benedict formula is not
change of dressing also affect dietary intake. Constipation
accurate, but for practical reasons it is often used. The
associated with frequent sedation and diarrhea due to changes
ideal body weight is used in the calculation of
in intestinal flora prevent the effectiveness of the nutritional
requirements, and BEE must be adjusted for activity and
strategies. Frequent surgical interventions and psychological
injury level. Activity factors are usually 1.2 for patients
alterations are also vital factors in nutritional therapy.
confined to bed and 1.3 for patients out of bed. Men: BEE
Energy requirements are increased due to enhanced (kcal) = 66.5 + 13.75 W + 5.0 H − 6.78 A, Women: BEE
expenditure energy associated with large area burns. This (kcal) = 655 + 9.56 W + 1.85 H − 4.68 A (W = weight in
is due to pain, anxiety, agitation, and heat loss during dressing kilograms, H = height in centimeters, A = age in years).
changes. Severely injured patients on mechanical ventilation The patient’s energy requirements are not constant and
or under sedation have reduced energy needs.[31] A decrease change frequently during the course of hospitalization.
in energy requirements by as much as 30% is achieved in Many criteria are not included in this formula, and the
critically ill patients by chemical neuromuscular paralysis. factors that needs to be considered are as follows:
The primary aim is to balance the increased caloric needs due Malnutrition in the presence or absence of TB and HIV/AIDS
to hypermetabolism and at the same time to avoid and the presence of preinjury protein-energy malnutrition is
overfeeding. an important factor.
30–33°C is considered optimal thermoneutral temperature for Age > 60 calculate as (20 × (weight in kg) + 65 × (%
the burn patient. The ambient temperature has an effect on the TBSA). [If percentage of TBSAB is greater than 50%, use
energy requirements. a maximum value of 50%]. Curreri formula example: A 30
Pain, anxiety, and stress increase the requirements. year male/70 kg weight sustained 50% TBSA burn. TEE
In the presence of thermogenesis, overfeeding must be = 25 kcal × 70 kg + (40 kcal × 50) = 1750 kcal + 2000 kcal =
avoided. 3750 kcal as total energy expenditure.[35] Caloric needs are
Energy requirements are reduced by 20% in burn patients on overestimated in burn patients by this formula.
ventilatory support.
The modified Curreri formula is widely used. It calculates
Pentobarbital use reduces energy needs to 86% of predicted
energy needs for each patient and is compared
energy requirements.
with the mean energy expenditure. Modified
Wound excision and skin cover in the early part of
Curreri = (20 × weight) + (40 × %TBSA) where %TBSA
management and availability of artificial skin help reduce
reaches a maximum value of 50 %TBSA.
the requirements.
Indirect calorimetry when available makes the assessments Ireton-Jones is a complex formula with variables for
easy and accurate. ventilated patients and for injury status.
(1) Ventilated patients: 1784−11 (age in years) + 5
The increased nutritional requirements of major burn injury (weight in kg) + (244 if male) + (239 if trauma) + (804
persists for more than 9–12 months following burn injury. if burn).
Nutritional needs do not decrease immediately following (2) For non-ventilated patients: 629−11 (age in
wound closure. Restoration of muscle mass and strength is years) + 25 (weight in kg) − (609 if obese).
achieved by progressive exercise program combined with
adequate nutrition. Galveston formula calculation is based on the age group and
helps in maintaining body weight.
Toronto formula (TF) is a useful tool where the nutrient
Age group 0–1 year: 2100 (BSA) + 1000 (BSA × TBSA)
intake has been standardized in terms of substrate
Age group 1–11 years: 1800 (BSA) + 1300 (BSA × TBSA)
composition. It is useful in acute stage of burn care.
Age group 12–18 years: 1500 (BSA) + 1500 (BSA × TBSA)
Adjustment is needed with changes in parameters during
where BSA is body surface areas; TBSA is total body surface
the process of monitoring.
area of burn.
EBEE (men) = 66.47 + (13.75 × W) + (5.0 × H) − (6.76 × A)
EBEE (women) = 655.1 + (9.56 × W) + (1.85 × H) −
(4.68 × A) When to reassess calories needs: Weight gain is common
W—weight in kilograms, A is age, and H is height in cms. during the resuscitation phase. The fluids are generally
mobilized slowly over the next 2 weeks to 1 month period
as the wounds heal and the patient recovers. Therefore, as the
TORONTO FORMULA FOR ALL PATIENTS weight begins to trend downward and the wounds are being
REE (kcal) = –4343 + (10.5 × %TBSA burned) + closed, it is important to reassess calories and protein
(0.23 × CI) + (0.84 × EBEE) + (114 × Temp (C) − (4.5 × days requirements. Weight of the patient is monitored closely.
postburn) There should not be a fall of more than 10% below baseline
[%TBSA—% of total surface area burn: CI is calories weight and also should not gain excessive weight.
received in the previous 24 h including all dextrose
infusions, parenteral, and enteral feedings; Temp is the Direct and indirect calorimetries are the best and accurate
average of the hourly rectal temperature of the previous means of basal energy expenditure measurement. Direct
24 h expressed in “C”; and PBD is the number of postburn calorimetry is known as whole room calorimeter monitors
days]. and the person is placed inside the calorimeter chamber.
There is space for moderate activity inside the chamber
The Curreri formula calculates energy needs of burn and the amount of heat produced is measured. Indirect
patients, and has the disadvantage that during calorimetry (IC) measures accurate energy expenditure
convalescence period it overestimates the patient’s and is considered the current gold standard test. Due to
nutritional needs. the cost factor and technical issues related to its maintenance,
Following burn injury energy, expenditure is maximum It is not available in all burn care centers.[36] IC machine is
during the early postburn phase (7–10 days postburn) and connected to the patient by tight-fitting face masks in non-
Curreri equation is most accurate in assessing energy needs. ventilated patients or through ventilators to the patient who
This equation has not been validated in recent years. Consider are on ventilatory support. Indirect calorimetry measures the
using validated equations, for example, Brandi equation. If total volume of expired gas. Oxygen and carbon dioxide
Curreri formula is used, compare with averages. concentrations in inhaled and exhaled air are also measured
and analyzed. O2 consumption of the patient is used to
Curreri equation (age 16–59 years): TEE is calculated as calculate metabolic rate by indirect calorimetry. Oxygen
(25 kcal × kg actual body weight) + (40 kcal × % TBSAB; consumption (VO2) and carbon dioxide production (VCO2)
values derived and metabolic rate is calculated. Indirect INDIRECT CALORIMETRY—KEY POINTS:
calorimetry has another important application that it
identifies underfeeding or overfeeding in burn patient. The Resting metabolic rate (REE) must be estimated on admission
to hospital and evaluated at least on weekly once basis till
ratio of carbon dioxide produced to oxygen consumed
(VCO2/VO2) is defined as respiratory quotient (RQ). patient condition is stable.
IC must be performed before daily activities for accurate
Metabolism of specific substrates in the body may alter the assessment of RMR. Late night or early morning IC study is
ratio. ideal for accuracy of results.
(1) In unstressed starvation, fat is utilized as a major energy Indications for indirect calorimetry are obesity, development
source, which produces an RQ of <0.7. of infection, suspicion of sepsis, evidence of poor wound
(2) The normal metabolism of mixed substrates yields an healing, or ventilator dependency with inability to wean from
RQ of around 0.75–0.90. ventilator.
(3) Overfeeding is typified by the synthesis of fat from Calculate RMR value by IC and multiply by a factor of 1.3 to
carbohydrate resulting in an RQ of >1.0. calculate total energy expenditure. Add 20%–30% to the
derived value to compensate for the activity of patient,
The complications are overfeeding and difficultly in physical rehabilitation, and stress of wound care and other
weaning from ventilatory support.[37] In pediatric burn treatment procedures. The nutrition calculation must be based
patients high-carbohydrate diets are associated with a on this calculation.[38]
decrease in muscle wasting. RQs were never increased
Macronutrients (substrates) are compounds found in all
over 1.05 and they did not develop any respiratory
foods we consume and they provide the bulk of energy. The
problems. A metabolic cart is a medical device for
metabolic processes involve creation and degradation of
measure of O2 consumption. These devices are very
many products in the body that are essential for various
expensive; it may not be available in all burn care
biological processes in the body. Energy is produced by
facilities as they need routine maintenance and calibration.
metabolism of three macronutrients carbohydrates,
They also require technical expertise and personnel to
proteins, and lipids via different pathways [Figure 3].
operate. Indirect calorimetry accurately studies energy
needs over a period of 30 min. It cannot be used to The role of visceral proteins in critically ill patients:
calculate 24 h needs. Indirect calorimetry fails to calculate Albumin, transferrin, transthyretin, and retinol-binding
energy loss due to painful procedures like change of dressing proteins are visceral proteins and are mostly synthesized in
change, thermogenesis, and exercise in ambulatory patients. liver. Inflammation and impaired liver functions result in low
Figure 3: Metabolic pathways of carbohydrate, protein, and fat
blood levels of visceral proteins. Hypoalbuminemia is due to Protein requirements—key points (for adult burn patients
“capillary leak syndrome” characteristic of critically ill using actual weight):
patients. The capillaries are more permeable and albumin (1) Adults with extensive burns require protein need at 3.0
escapes into the interstitium. Distribution of albumin gets to 4.0 g/kg/day. Adults with BMI > 30 require protein at
affected with an infusion of various fluids used for volume 2.0 g/kg/IBW
resuscitation of sick patients.[39] Hence, albumin is not a (2) Desirable nonprotein kcalorie to nitrogen ratio (NPC:N)
good tool for assessment and cannot be used for monitoring in adult is 120 to 150:1.The desirable ratios are as
of the nutritional status. Patients with <50% of TBSA burns, follows:
show a rapid and consistent increase in levels of albumin and (a) 80:1 in patients with most severe stress
transthyretin from 12 to 43 postburn days. Biweekly (b) 100:1 in severe stress condition
measurements show a decline for those who died between (c) 150:1 in when patient is in unstressed condition
day 20 and day 43 postburn period. (d) 150:1–200:1 adequate intake for stable patients
Transthyretin levels indicate poor prognosis when less than Amino acids give cells their structure. They are essential in
50 mg/dL or failure to increase of 40 mg/L/week. transport and storage of nutrients and carry out many important
Immunonutrient-rich in nucleotides and omega-3 fish oil body functions. They supply energy to liver. Muscles, bones,
decreases the mortality rate along with decrease in skin, and hair require amino acids for tissue repair and wound
recurrence rate of bacteremia in sick patients in intensive healing. Functions of organs, glands, tendons, and arteries are
care. Increased proteolysis following severe burn results in also dependent on amino acids. They play an important role in
loss of more skeletal muscle daily. Protein administered must removal of all kinds of waste deposits and products of
meet the daily needs, give extra allowance of substrate to metabolism. Efflux of glutamine, alanine, and arginine from
prevent loss of lean body mass, support wound healing, and skeletal muscles and organs take place in large amounts
provide an adequate immune function. With limited following burn injuries. They play a unique role in recovery
availability of calories, protein is used as energy source. following burn injuries and their supplementation is crucial for
The reverse is not true. Excess of calories supplemented will final outcome of optimal results.
not increase protein synthesis or retention, leads to
overfeeding. There is no reduction of the catabolism of Glutamine: There is a rapid depletion of glutamine from
endogenous protein stores by supra normal doses of muscles and serum following burn injuries:
protein supplementation. It reduces negative nitrogen (1) Glutamine acts as a direct energy source for
balance by facilitating protein synthesis. Protein needs for lymphocytes and enterocytes.
adult burn injury patients are 1.5–2.0 g/kg/day and children (2) Maintains integrity of small bowel and preserves gut-
need 2.5–4.0 g/kg/day.[40] Maintain nonprotein calorie to associated immune functions.
nitrogen ratio between 150:1 for burns involving small (3) It is a source of energy for hepatocytes. It maintains
area and 100:1 for larger area burns. Loss of muscle integrity, permeability, and immune function of small
protein in burns patient is due to the hormonal and pro- intestine.
inflammatory response despite high rates of nutritional (4) Heat shock proteins provide cellular protection
therapy. following stress caused by burn injuries. Glutamine
increases the production of heat shock proteins.
Calculation of protein needs based on TBSA of burn: Glutamine is a precursor of glutathione, which is a
Protein supplementation must be based on various factors critical antioxidant.
such as wound status, medications received by the patient, (5) Glutamine improves wound healing.
renal and liver function status. All patients with >30% TBSA (6) Glutamine is administered at a dose of 2.5–0.3 g/kg/day.
burn receive glutamine enteral supplementation. Based on It helps to reduce mortality and shorten the length of
ideal body weight, Glutasolve powder is given to provide hospital stay in burn patients.[41,42,43]
0.3–0.5 g/kg/day of protein [Table 3]. If the patient develops
multisystem organ failure or encephalopathy, glutamine
supplementation must be discontinued. ARGININE
Stimulates T lymphocytes and augments performance of
natural killer cells.
Table 3: Protein estimation in adults burn patients based Improves resistance to infection by enhanced nitric oxide
on the actual or lean body weight synthesis.
Improvement in wound healing and immune responsiveness
Burn percentage Protein supplementation
has been documented following administration of arginine in
Less than 10% TBSA burn 1.2–1.5 g/kg body wt burn patients.
10%–15% TBSA burn 1.5–2.0 g/kg body wt Zinc supplementation in high doses leads to copper
15%–35% TBSA burn 2.0–2.5 g/kg body wt deficiency.[44,45] During high dose supplementation of
>35% TBSA burn 23%–25% of total energy micronutrients, the possible interactions between them
Body weight is actual or ideal body weight in kilograms. must be considered.
Carbohydrates: High-carbohydrate diets have a protein- burn injury. They lead to a rapid and sustained depletion of
sparing effect and promote wound healing. Hence, the endogenous antioxidant defenses. The oxidant defense
carbohydrates are favored and extremely crucial part of the mechanisms are highly dependent on levels of
diet plan for burn patients. Glucose can be oxidized and used micronutrients.[52,53] Vitamin and trace element
in severely burned patients at a maximum rate of 7 g/kg/day metabolisms are crucial in development of immunity and
only. Even though severely burned patients have high glucose wound healing.
levels, it is not in sufficient caloric amount required to prevent The process of wound healing, skeletal muscle bulk, and
loss of lean body mass. Excess of glucose more than what can immune functions are adversely affected due to deficiencies
be used in the body leads to hyperglycemia. Conversion of of vitamins A, C, and D, trace elements such as Fe, Cu, Se,
glucose to fat occurs and there is an associated glucosuria, and Zn.
dehydration, and leads to respiratory complications. Increased epithelial growth of vitamin A decreases time of
wound healing. Retinoids favor macrophagic inflammation
Glycemic control in burn patients by insulin therapy:
that supports wound healing.
Acute injury and hormonal environment of stress due to burn
Vitamin C is important for creation of collagen and their
injuries leads to insulin resistance. Insulin maintains adequate
cross-linking functions.
and satisfactory blood sugar levels. Excessive growth
Vitamin D becomes deficient following burn injury. It
hormone due to stress response opposes the effect of
contributes to bone density. The exact role of vitamin D
insulin in the liver and in peripheral tissues. This causes
and optimal dose following severe burn remains unclear.[54]
lipolysis by uncoupling insulin-stimulated P1 3-Kinase from
High doses of zinc supplementation lead to copper
its downstream signals. A decrease in anabolic
deficiency.
(Somatotropic) peripheral effect of GH is due to a
decrease in IGF-1 and IGFBP-1 hormone that catalyze The trace elements such as Fe, Cu, Se, and Zn are important
skeletal hypertrophy and protect myocytes from protein for both cellular and humoral immunity. Trace elements are
catabolism. Anabolic effects never manifest since secretion lost in large quantities in exudates of burn wounds.
of IGF-1 is inhibited, even though there is GH-driven increase Zinc is important for function of lymphocyte, replication of
in insulin resistance and an increase in lipolysis.[46] Glucose DNA, and synthesis of protein. It is critical for wound healing
levels between 5 and 8 mmol/L has several clinical benefits of also.
good graft uptake, lesser infectious complications and For oxygen-carrying proteins, iron (Fe) acts as an important
ultimately decreased mortality. The standard target of cofactor. Selenium enhances cell-mediated immunity
100–150 mg/dl is maintained in other critical patients in [Table 4].
ICU. Exenatide is a new incretin that inhibits glucagon Copper is required for optimal wound healing, synthesis of
secretion and decrease external insulin requirement in collagen. Its deficiency is associated with decreased
pediatric burn patients. Infusion of insulin, along with immunity and cardiac arrhythmias. It leads to worse
high-carbohydrate, high-protein diets, has many clinical outcome in patients with burn injuries.
benefits in severely burned patients. Donor site healing Morbidity of severely burned patients improves with
improves; lean body mass and bone mineral density are replacement of these micronutrients.[55]
maintained. Muscle protein synthesis is enhanced, wound
healing is accelerated, and there is a decrease in length of Ceruloplasmin and hypoferremia: In critically ill burn
hospital stay.[47] Patients on insulin therapy require close patients, normal iron handling mechanisms are altered.
monitoring to avoid hypoglycemia. The resultant hypoferremia contributes to systemic
inflammation.
Lipids are recommended only in limited amounts. Fat as a
nutrient prevents deficiency of essential fatty acid.[48] During
the hypermetabolic state there is an increase in beta-oxidation
of fat and that provides fuel. Lipolysis is suppressed after Table 4: Daily requirement of vitamins and minerals
burn injury. Use of lipids as a source of energy is decreased. Vitamin Specific component Daily dose
Only 30% of free fatty acids are degraded. Remaining free
Vitamin B complex Thiamine 10 mg
fatty acids go through reesterification process and get
Riboflavin 10 mg
accumulated in the liver. Immune function is adversely
Niacin 200 mg
affected by increased fat intake.[49] Very low-fat diets that
Vitamin B6 20 mg
supply no more than 15% of total calories is recommended for Folate 2 mg
patients. The amount and the composition of fat must be Vitamin B12 20 mg
considered.[50,51] Multiple low-fat enteral formulas are Vitamin C 2g
available. For patients receiving PN on a short-term (<10 Minerals Selenium 100 mg
days) it may not be necessary to add lipid emulsions. Copper 2–3 mg
Zinc 50 mg
Micronutrients: Intense oxidative stress and elevated Manganese 25–50 mg
inflammatory response are characteristic features of severe
Ceruloplasmin (Cp) is an acute phase reactant protein wound healing, and shorten hospital stay. Thiamine
important in regulation of iron metabolism. Cp converts replacement improves lactate and pyruvate metabolism.
ferrous iron to ferric iron, which is a less reactive form Vitamin C and E supplementation enhance wound
and helps in binding to ferritin. The ferroxidase activity of healing. It is recommended that the patients receive
ferritin is important in iron handling mechanisms. Genetic 1.5–3 times the dietary reference intake. Loss of
absence of Cp causes iron accumulation in many organs as vitamin D must be supplemented to prevent bone loss.
there is a decrease in export of iron. Hypoferremia and Increased oxidative stress in burn patient enhances
inflammation occur due to an early decrease in Cp oxidase depletion of micronutrients.
activity in both burn and nonburn trauma patients. There is an
increase in the risk of iron-induced injury following blood
transfusions in patients with critical burn injuries. “Stress VITAMIN-D REQUIREMENT IN ADULT BURN PATIENTS:
hypoferremia,” a low iron status in critically ill or injured 25OH-D level following burn is lower than healthy subjects
patients, occurs irrespective of severity of injury, blood on admission.
transfusions status, surgical procedures, or sepsis.[56] Some Elevation in levels of 25OH-D and free 25OH-D with
studies have reported links between iron status and severity of 100,000 IU of cholecalciferol is not clearly documented in
injury.[57,58] burn patients compared to healthy subjects.
Development of low serum or plasma iron concentrations in During acute burn care, higher cholecalciferol doses should
burn injury patients is documented. Critical burn injury be considered.
patients develop anemia.[59,60] Quarterly vitamin D injections (200,000 IU) helped muscles
The changes that occur in the first week following burn injury in adult burn patients.
are related to low iron binding capacity and serum transferrin
concentrations. Soluble transferrin receptor levels are a Immunonutrition: The aim of immunonutrition is to achieve
reliable indicator of iron deficiency anemia in hospitalized wound healing and improve immune function. Nutritional
patients with acute illness and there is a significant lower formulas enriched with micronutrients help in better outcome
level of iron in burn patients than in trauma patients until day of patients. Severely burned children, on tube fed formula
14. [61] with omega-3 fatty acid, arginine, histidine, and vitamins A
and C were compared to children on commercial formulas.
The changes are similar to hypoferremia of inflammation Children on IED had distinct benefits of reduced wound
related to cytokine induced release of hepcidin.[62,63] infections, shorter length of hospital stay, and showed
Reduced Cp oxidase activity carries the risk of iron- improved survival rates.[67] Immunonutrition with
mediated injury following transfusion with aged blood immune-enhancing diets (IED) showed beneficial effects
near its 42 day storage limit. and lead to
improved respiratory gas exchange,
Micronutrient supplementation is crucial in reducing the
an improvement in neutrophils recruitment,
mortality and morbidity in critically ill patients following
improved cardiopulmonary function, and
burn injuries. Deficiency results in lowered host defenses and
reduced the number of days required for mechanical
impaired production of antioxidants. Copper, zinc and
ventilation and length of hospital stay.
selenium are lost in larger amounts in burn patients in
the exudates.[64,65,66] The intravenous route is best for their According to some studies, there is no difference in major
replacement. Duration, dose and timing of micronutrient outcome variables with immune-enhancing diet compared to
supplementation are important considerations for high protein stress formula diets.[68] Since the patients are on
improving their utility. high volume feedings, conventional diets supply an adequate
Addition of copper, zinc, selenium, vitamins B1, C, D, dose of most immune-enhancing nutrients. It is concluded
and E to the supplement food is of great value that no formula or calculation is perfect, but most are
[Table 5]. They decrease fat breakdown, improves sufficient to prevent nutrition-related complications.
Table 5: Micronutrient requirements in critical burn patients

Micronutrient requirements
Electrolytes Electrolytes are administered based on serum and urine analysis and fluids infused
Minerals Dietary reference intake
Trace elements Dietary reference intake
Children and adults with minor burns (<20% One multivitamin intake daily
TBSA burn)
Children younger than 3 years with major burns One multivitamin intake daily along with vitamin C 250 mg twice daily: vitamin A 5000 IU
(>20% TBSA burn) daily and Zinc sulfate 110 mg daily
IMMUNONUTRITION AS AN ADJUVANT THERAPY FOR Gottschlich formula has reasonable impact on burn wound
infection rates and length of stay expressed as days per %TBSA.
BURNS This formula is a high-protein, low-fat diet with a low-linoleic
Immunonutrition is feeding along with enteral route or total acid content, supplemented with omega-3 fatty acids, arginine,
parenteral nutrition supplementations. They are enriched with cysteine, and histidine. Vitamin A, zinc, and ascorbic acid are
various pharmaconutrients. The most essential and also added in this formula.
commonly used are arginine, glutamine, omega-3-fatty Kurmis and associates (2010) have recommended that glutamine
acids, nucleotides, and antioxidants: copper, selenium, alone be used in patients with severe burns. The European
zinc, vitamins B, C, and E. They improve immune Society for clinical nutrition and metabolism (ESPEN) has
response in patients and also modulate and attenuate the not issued statement regarding combination therapy.[73]
severe responses of inflammation [Table 6]. Complete
supplemented nutritional formulations are “Immune Probiotics are defined as live microorganisms that when
modulating diets” (IMD). The potential targets for administered in adequate amounts, confer a health benefit on
immunonutrition include: the host (WHO). Metchnikoff, a Russian Scientist,
gastrointestinal: the gut mucosal barrier function has to be introduced the concept of probiotics. Probiotics are found
maintained, in large quantities in yogurt, kefir, and fermented foods. They
boost cellular defenses, and help enhance the defensive action of the cells that line the gut.
modulation of local and systemic inflammation. They stimulate healthy immune function and inhibit the
growth of viral and bacterial pathogens. High through
The common nutrients added in immunonutrition formulas Table put-sequencing technology and advances in meta-
include glutamine, arginine, branched-chain amino acids genomics have opened up new approaches for the future
(BCAAs), omega-3 (n-3) fatty acids, and nucleotides. of probiotics research. The study of molecular biology and
Omega-3 fatty acids form major component of “immune- genomics of Lactobacillus help in enhancing immune
enhancing diets.” The most used common formulas contain function and as an adjuvant treatment of cancer. Other
linoleic acid, an omega-6 fatty acid. They go through the uses are in treatment of antibiotic-associated diarrhea,
process of synthesis of arachidonic acid, precursor of pro- travelers’ diarrhea, pediatric diarrhea, inflammatory bowel
inflammatory cytokines (e.g., prostaglandin E2). disease, and irritable bowel syndrome. The benefits of
Lipids containing a high percentage of omega-3 fatty acids do probiotics include:
not promote pro-inflammatory molecules during their relief of stress, anxiety, and depression,
metabolism. The beneficial effects are an enhanced mood improvement via gut-brain signaling,
immune response, reduced levels of hyperglycemia, and protection against free radicals,
improved clinical outcomes. improvement of glucose tolerance,
An omega-6 to omega-3 ratio of 4:1 is ideal. Omega 6:3 ratio allergy prevention,
is maintained between 2.5:1 and 6:1 in enteral formulas and cholesterol reduction, and
the immune-enhancing diets have omega 6:3 ratio closer to beneficial effects in liver disease.
1:1. Further understanding and research are required to
identify the ideal composition and amount of fat in The commonly used marker of inflammation is CRP.
nutritional support for burn patients. Treatment with prebiotics showed decreased levels of
CRP more than bacterial sonicates. It is associated with
COMBINED IMMUNONUTRIENTS reduced levels of serum hs-CRP and an increase in serum
albumin levels.
Glutamine is the most commonly used immunonutrient.
Various combination of immunonutrient regimens have Probiotics effects on nutritional status: Lactobaciillus
been used in patients with extensive burn injury.[69,70,71,72] johnsonii is a species in the genus Lactobacillus. The
Table 6: Classification of immunonutrient and their functions

Glutamine It is nonessential amino acid—“conditionally Involved in many metabolic processes/nitrogen carrier/
essential” amino acid important source of energy for cells
Ornithine a- Immunonutrient precursors Anti-catabolic actions are through insulin. It has modulatory effect on
ketoglutarate (OKG) human growth hormone
Branched-chain amino They are the endogenous precursors of amino acids such as glutamine/supports immune function. Reduced levels of BCAA
acids impairs immune function, such as killer cell activity and proliferation of lymphocyte proliferation
The n-3 fatty acids Helps to reduce levels of inflammatory prostanoids and endogenous immune-suppressive mediators
Dietary nucleotides They act as substrate for immune cells function during stress/maintain gastric mucosal integrity and function
Antioxidant Zinc, selenium, copper/vitamins B, C, and E
supplements
probiotic L. johnsonii La1 (LC1) in fermented milk has almonds, hazelnuts, kale, collard greens, Chinese greens, etc.,
beneficial effects on serum albumin levels. Calcium supplement or other calcium-fortified foods may be
Suppresses infections and in elderly patients it improves necessary depending on the deficiency status. Iodine is
nutritional and immunological status.[74] available from sea vegetables and iodized salt. Iron:
It has a positive effect on albumin biosynthesis with increased Vegans must eat iron-rich and vitamin C-rich foods daily.
serum albumin levels. Dark leafy greens together with other sources of vitamin C are
Decrease in TNF-a was identified in the LC1 treated group. ideal for supplementation. Choline: Vegan diet sources rich
Blood phagocytic activity is a natural immunity marker in in choline are soy lecithin, cauliflower, spinach, wheat germ,
patients with low serum levels. An increase in blood firm tofu, kidney beans, quinoa, and amaranth. Adequate
phagocytic activity has been documented in the LC1 intake of choline per day for adult women is 425 milligrams;
treated group. pregnant and breastfeeding women need greater amount. An
adult male requires 550 mg/day. Choline has anti-
Synbiotics enteral nutrition in the early burn period helps to inflammatory effect. Adequate and quality choline
reduce the inflammation of the stress response and also requirements may be achieved with wheat germ (172 mg/
increases serum levels of albumin. Probiotics are not cup), Brussel sprouts (63 mg/cup), and broccoli (62 mg/
involved in stimulation of production of gastrointestinal cup).[78,79]
protein synthesis and they do not reduce severity of colitis.
The probiotics-induced elevation in liver protein and
synthesis of plasma proteins are modified through a
DIETARY MODIFICATIONS IN SPECIAL SITUATIONS
signaling mechanism between the gut and liver.[75] Effect Endocrine disorders: Normal functioning of many
on weight gain: Infants on a supplement dose of prebiotics endocrine organs such as thyroid, pancreas, etc., is also
have slightly better weight gain. linked to the nutritional status. Thus, nutritional imbalance
can hamper their normal functioning. Various endocrine
Prognostic inflammatory and nutritional index: PINI is a disorders such as obesity, thyroid disorders, and diabetes
clinical prognostic index assessment tool related to outcome have been linked with dietary modifications. Increased
prognosis in hospitalized elderly patients and in critically ill prevalence of endocrine disorders is associated with
patients with acute respiratory failure.[76,77] Serum CRP, overnutrition. Dietary patterns actually program the
alpha 1-acid glycoprotein (AAG) and albumin (ALB) different mechanisms associated with these disorders. As
levels are considered in a single score. in case of diabetes mellitus, presence of transcription
Vegan nutrition diet includes no animal products and refers factor TCF7L2 can be regulated by fat and glucose rich
to their nutritional aspects. Vegan diets are based on the belief diet. All the dietary components affect endocrine systems
that high animal fat and protein diets are detrimental to health. of the body. Chronic kidney disease: Dietary modifications
Vegan diets must be planned and executed carefully. Vegan both improve symptomatology as well as progression of
diets may be deficient in a variety of nutrients and a careful kidney diseases.[80] Many factors like type and severity of
planning is essential to avoid deficiencies of such nutrients. renal disease, nutritional status, dry weight, dietary intake, co-
Riboflavin (vitamin B2), vitamin B12, and vitamin D are the morbid diseases, physical activity, biochemical markers, and
common vitamins deficient and also calcium, iodine, iron, also the adjusted body weight help in calculation of energy
zinc, long-chain fatty acids EPA and DHA, and omega-3 fatty requirement of these patients.
acids need a planned supplementation. Nonnutritional strategies in the management of
Vitamin B12: Vegans must follow one of the dietary options hypermetabolism aims at attenuation of the
for getting sufficient levels of vitamin B12: hypermetabolic stress response to burn injury and are
3 micrograms of vitamin B12 will be reached by consuming recommended in addition to early enteral nutrition. The
fortified foods 2–3 times per day. following factors help reduce the severe hypermetabolic
To get at least 10 micrograms of B 12, take 1 vitamin B12 response of burn injuries:
supplement per day. Nursing environmental temperature at 28–30°C is ideal. The
To get at least 2000 micrograms, take 1 weekly B12 warm ambient temperature reduces the metabolic needs in
supplement. burn patients.
Excision and coverage of burn wounds as early as possible
reverses the severe catabolism associated with burn wounds.
Omega-3 fatty acids (O3FA) are available in plenty in algae, Protein building mechanisms of the body can be strengthened
hemp-seeds, and hemp-seed oil. Other rich sources include by using protein synthesis stimulating agents.
flaxseeds and flaxseed oil, olive oil, canola (rape seed) oil, Metabolic resuscitation of burn injury patients includes
and chia seeds. Walnuts and avocado are the other rich adequate pain control. Early institution of exercise therapy
sources of O3FA. Calcium: Enough calcium program helps in rehabilitation in such patients.
supplementation can be achieved with high-calcium food,
such as fortified soy milk and other plant based milks, taken Propranolol use in children has shown more positive effects
on three servings per day. Other rich sources of calcium are than in adult patients with burn injuries. Nonselective beta-
blocker propranolol in adults help decrease in requirements undergoing major surgical procedures. In adult patients
for blood transfusions, hastens wound healing, and reduces with burn injury, their effects are not better than
the number of skin graft procedures required. These are oxandrolone. Use of rhGH has no adverse impact on
associated with reduced length of hospital stay (LOS). The mortality but has adverse hyperglycemia effects. In
dose of propranolol that reduces basal heart rate by 20% has children with critical burn injuries, rhGH effectively
significant effect in decreasing the release of cytokines or preventing growth impairment (stunting) caused by GH
stress hormones. This leads to a reduction in both deficiency of critical burn injuries. Treatment with rhGH
hypermetabolism and hypercatabolism response in (0.05–0.2 mg/kg/day) enhances skin graft donor site healing,
critically ill burn patients. Propranolol is started at the end reduces hypermetabolism and growth deficit.[85,86] Treatment
of first week of burn injury.[81,82] It is administered at a dose for up to one year has shown to be effective and safe. Ideal
of 0.1 to 3.8 mg/kg/day (an average maximum dosage of duration of treatment is still under study and patients may be
0.61 mg/kg/day). The mean heart rate decreases by 25% benefited from a long term administration of rhGH.
during 4 weeks of treatment. It is important to monitor the
Monitoring of nutritional support: The goal of nutritional
patients for possible bradycardia and hypotension.
support is to get back normal body levels of all nutrients and
Fenofibrate, a fibrate is an anti-hyperglycemic therapy achieve a state of metabolic equilibrium. Objective methods
without the risk of hypoglycemia. Administration of of assessment and monitoring of nutritional support of a burn
fenofibrate in the early acute phase reduces blood glucose patient is a challenge. They cannot be measured by one
levels in severely burned patients. It also causes blockade of variable alone as it is a complex phenomenon. Weight of
catecholamines, with attenuation of long-term postburn the patient, lean body mass, nitrogen balance, and serum
effects of catabolic and hypermetabolic responses. proteins estimation are the most common factors used. Body
Fenofibrate alone or in combination with propranolol weight is easy to measure and is useful to assess for
reduces insulin resistance, enhances wound healing, nutritional monitoring in general population but it is very
improves cardiac function, and reduces sepsis-related misleading in burn patients. Critical burn patients receive
complications when administered for duration of one year large volume fluid resuscitation in initial phase of injury, may
postburn. Proposed clinical trials are on therapeutic, have a weight gain of about 10–20 kg. Later on with diuresis
physiological, and metabolic effects of propranolol, there may be a reduction in body weight and the time course is
fenofibrate, and fenofibrate plus propranolol on the unpredictable. Ventilator support, infections, and
improved clinical outcomes, and the long-term recovery, hypoproteinemia are also associated with additional fluid
rehabilitation, and QOL in burned patients. Oxandrolone shifts. These make the body weight measurement a very
are nonselective beta-blockers that decrease mortality. The unreliable gauge of nutrition. Loss of lean body mass that
length of hospital stay is decreased at a dose of 10 mg every occurs in the early period of burn injury is marked by the
12 h. The beneficial effects include prevention of loss of presence of increased total body water in patients that persists
weight, protein catabolism, and hasten healing time both for weeks following burn injuries. Long-term body weight
during acute and rehabilitation periods. It is useful in the monitoring is valuable especially during the rehabilitation
metabolism of bone also. Children who receive oxandrolone phase. Nitrogen balance: Nitrogen occurs in all organisms.
at 0.1 mg/kg/12 h also get the same benefits as seen in adults. Primarily, it is fundamental component of amino acids, of the
Liver function requires a close monitoring during the nucleic acids and of energy transfer molecule adenosine
administration of oxandrolone.[83,84] triphosphate. Nitrogen intake and losses are good
predictors of protein metabolism. Adequate quality protein
The best cost-effective pharmacotherapy for burns
supplementation is crucial in nutrition therapy following burn
hypermetabolism is propranolol and oxandrolone. Clinical
injury. An increase in the total body protein levels associated
research is underway for the role of a combined therapy
with growth indicates a positive nitrogen balance. Burn
with propranolol and oxandrolone (NCT00675714). Early
injuries, trauma, and periods of fasting are characterized
administration of both drugs alone/in combination during the
by negative nitrogen balance. Determination of urinary
first week of burn injury is under study. Propranolol
urea nitrogen (UUN) and dietary nitrogen intake are used
administration begins at the end of the first week, after the
in calculation of nitrogen balance for burn injury patients:
initial resuscitation phase and oxandrolone is administered a
Nitrogen balance = Nitrogen intake in 24 h −
little later. Treatment duration must correspond to the
[1:25 × (UUN + 4)]. (Factor 4 is nitrogen losses from non-
hospitalization stay and modifications are required regarding
urinary sources) The two constants used in the formula may
propranolol and oxandrolone during septic events. A prolonged
result in errors in calculation. A value of 4 g/dL is added to
administration of these drugs during the rehabilitation phase
UUN to calculate the total urinary nitrogen. But in burn
might be considered with better clinical outcomes.
patients total urinary nitrogen may exceed this value and
Recombinant human growth hormone: rhGH promotes lead to an underestimation of nitrogen loss.[87] To account for
utilization and synthesis of protein. When used in patients’ loss of protein-rich exudates from burn wounds, the estimated
burns with >40% TBSA, it has well documented anabolic total urinary nitrogen value is multiplied by a factor of 1.25.
effects in patients with major burn injuries and those This also can underestimate nitrogen losses.
Albumin and Prealbumin are acute phase proteins. During twice a week for all patients with critical burn injuries in
acute phase inflammatory processes such as infection, burns, BICU and patients who do not require BICU care must be
and trauma, these protein levels are reduced and they are evaluated at least once in a week. Serum albumin levels and
called negative acute phase reactants. Burn injuries elicit local caloric intake do not link with each other, but are associated
and systemic inflammation, increased vascular permeability with CRP and wound healing. Serum albumin is not a good
and hypermetabolism that lead to decrease in serum albumin index as a nutritional status marker in patients with burn
levels. Prealbumin has a short half-life of 2–3 days and is a injuries.
better indicator of nutritional repletion. Prealbumin levels fall
Prealbumin as a Marker for Nutritional Evaluation:
rapidly following injury, has a slow recovery, and are not
Prealbumin is a hepatic protein, serves as a good indicator
accurate estimators.[88] Serum albumin is a negative acute-
for assessment of the severity of illness due to malnutrition.
phase reactant protein. There is an enhanced acute-phase
Prealbumin is reliable and a preferred marker for protein
protein synthesis in the liver due to high levels of
malnutrition in critical burn injury patients. Most important
inflammatory cytokines in burn injury patients. Synthesis
source of prealbumin is liver. Significant levels are secreted
of albumin as a negative acute-phase protein decreases in
from the choroid plexus, embryonic yolk sac pancreatic islet
the acute inflammatory response phase of burns and result in
cells, and gastrointestinal mucosal enterochromaffin cells are
hypoalbuminemia. Serum albumin level is a good marker of
other sources. Estimation of prealbumin serves as a sensitive
wound healing, but poor marker of nutritional status in
and most cost-effective method for estimation of nutritional
patients with burns. Burn wounds have a high vascular
status. Prealbumin levels are accurate predictor of patient
permeability and produces exudation of protein. Fluid
recovery and they correlate well with patient outcomes. Liver
resuscitation also makes proteins estimation an unreliable
continues to produce prealbumin until late in liver disease.
tool. Serum albumin and CRP levels (half-life of about 20
Prealbumin levels are estimated twice weekly in high-risk
days and 4–6 h respectively) fluctuate independent of each
patients, to identify declining nutritional status of the patient,
other. Hypoalbuminemia is a good prognostic marker
improve patient outcomes, shorten hospital stay duration in
correlating with mortality and morbidity in hospitalized
cost-conscious situations.
patients. It also indicates disease prognosis and
development of complications. There is no difference in
serum albumin levels in relation to the levels of caloric
KEY POINTS:
intake in individuals with burn injuries. Prealbumin level estimations allow early recognition and
timely nutritional intervention.
In a normal adult person consuming food that provides only
KEY POINTS: 60% of required proteins, prealbumin levels start decreasing
Serum levels of albumin are not good indicators of nutritional after 14 days.
status and they are not reliable as nutritional markers. In children with severe protein calorie malnutrition, protein
Nutritional status assessment in burn injury patients with supplementation rises the prealbumin above baseline levels
albumin is unreliable. within 48 h and takes 8 days to reach normal levels.
There is no relationship between good caloric intake and Aim of nutritional support must enhance prealbumin levels by
serum albumin levels. Malnutrition or inadequate provision 2 g/dL (20 g/L) per day.
of nutrients is not reflected as low albumin levels either.
There is a large body pool of albumin (half-life of 20 days). Limitations of prealbumin level: Acute alcohol intoxication
The state of hydration and renal function of patients affect rises prealbumin levels. This is due to leakage of proteins
serum albumin concentrations. from damaged hepatic cells. The elevated prealbumin level
When albumin pool gets depleted, it takes 14 days to return returns back to normal after one week. Prednisone therapy
back to normal. and use of progestational agents increases prealbumin levels.
Zinc deficiency lowers prealbumin levels and vitamin
Prealbumin and CRP levels: Mediators of inflammation deficiencies do not have effect on the serum levels of
associated with sepsis, trauma, and burn injuries alter the prealbumin.
metabolism of negative acute phase proteins. There is a
reduction in their synthesis and also dilution of negative PREALBUMIN—KEY POINTS:
acute phase proteins. The values of albumin, prealbumin, Prealbumin levels below 15 mg/dL (150 mg/ L) require the
and transferrin in the acute phase of the thermal injury are less services of a nutritional team and therapy must be planned
sensitive index of nutritional repletion. Following the acute and monitored by the team.
phase when intake of nutrition is adequate serum prealbumin An increase in prealbumin levels occurs within 4–8 days of
level (half-life 48–72 h) gradually rises. CRP, a positive acute nutritional supplementation therapy.
phase protein levels gradually decrease. Persistent low level Within 8 days of nutritional support, a prealbumin level of
of prealbumin in the presence of normalizing CRP level is a 4.0 mg/dL (40 mg/L) must be achieved, failure to achieve
good indicator of protein or calorie deficiency.[89] indicates a poor prognosis and need for additional support
Estimation of prealbumin and CRP levels must be done measures such as oral or intravenous hyperalimentation.
If prealbumin level continues to rise, it indicates that patients times per week with infusions of 250 mL of 20% is essential
are receiving at least 65%of their requirements of protein and to meet fatty acid requirements.
energy.
Nutrition support strategies: Evaluate ability of critically ill
Functional tests are useful but not absolutely essential for burn patients to receive enteral feedings at the time of
routine assessment of nutritional status. For voluntary muscle admission. During initial aggressive fluid resuscitation,
strength exercise tolerance test and hand dynamometry are there is poor intestinal perfusion as a result of disparity in
the common tests done. Strength of respiratory muscles is intestinal oxygen demand and perfusion. This important
assessed by measurement of peak expiratory flow rate. Other aspect requires careful consideration while choosing the
scores of well-being such as mood score and quality of life route of feeding. For patients with diminished gut
score and in elderly patients activity of daily living score are perfusion trophic feeds are ideal and this includes patients
used. who are in need for treatment with vasopressors.
Reassessment is done once the patients are
hemodynamically stable. A baseline measurement of
IMAGING TECHNIQUES FOR NUTRITIONAL MONITORING: abdominal girth is obtained on admission. Gastrointestinal
Bioelectrical impedance analysis (BIA) sends a weak output of less than 200 mL with stable abdominal girth
electric current throughout the body to calculate body measurement indicates that the patient can tolerate gastric
composition. It is a simple, noninvasive, and indirect feedings. Hourly feeding rate of 0.5–1 mL/kg will be easily
method of assessment. Total body water and body’s fat- accepted. Gradual increase in feeding rate must be done with
free cell mass estimate are based on the body’s resistance continuous monitoring of GI output and abdominal girth
to passage of electrical currents. Shifting of fluids measurement. The feeding must be stopped when the
characteristic of burn injuries affects this method of gastric residuals exceed two times the volume of hourly rate.
measurement. They are used in research only due to
Discriminate intravenous lipid administration interferes
availability and cost involved.
with platelet function, predisposes to poor immune function,
Dual X-ray absorptiometry (DEXA) scan is a measure of
and exacerbate lung injury. Allergy to soy and eggs are
bone density and is also used to estimate lean body mass.
contraindicated. Intravenous lipids must be avoided and
used when parenteral support is required to be provided in
THE MOST COMMON PARAMETERS USED IN excess of 3 weeks.
ASSESSMENT OF NUTRITIONAL THERAPY ARE AS Enteral nutrition: Following trauma and severe burn there is
FOLLOWS: gut ischemia and reperfusion during the initial period of
resuscitation. Development of sepsis and multiple organ
Different burn care centers have their own protocols of
failures are related to these changes. Parenteral nutrition
burn managements. The most commonly used tests for
composition selection is crucial in preventing infections and
nutritional assessment are prealbumin estimation in 86%
hepatic dysfunction. Composition and rate of administration
of centers, Body weight measurements are followed in
of solution is more important to avoid such complications.
75%, and calorie estimation by direct or indirect
Proper care of the central venous line used for providing this
calorimetric studies in 69% of centers. The other
form of nutrition is also essential. Adult and children with
estimates made are serum albumin (45.8%), analysis of
burn injuries cannot oxidize efficiently when glucose is
nitrogen balance (54%), and transferrin levels in 16% of
administered in excess of 5 mg/kg/min, the goal infusion
burn centers.
rates in burn patients. Fluid edema and complications like
Formulas for nutrition in burn patients: Milk and hepatic steatosis and other metabolic derangements can be
eggs were the main constituents of nutritional formula prevented by avoiding overfeeding by keeping the glucose
for burn patients, before the advent of the latest infusion within this limit. The incidence of hyperglycemia is
technologies in nutrition therapy. They successfully also minimized. Amino acid infusions supply the entire
provided adequate nutrition but the disadvantage was estimated protein requirement in critical burn injury
the very high fat content. Carbohydrates along with patients to maintain the nonprotein calorie: nitrogen ratio
protein, fats, and added micronutrients of various of 85:1. Wound healing is enhanced at this level of nutritional
quantities and in combinations enteral formula are support.
available commercially.
The scope of enteral nutrition has improved with advances in
In burn injury patients, glucose is the preferred energy Endoscopic placement of jejunostomy and gastrostomy
source. The basis for nutritional plan for burn injury patients feeding tubes.
includes a diet rich in carbohydrates. Common parenteral Development of various new biomarkers of illness is of great
formulas contain 25% dextrose with addition of 5% help in guiding the nutritional goals.
crystalline amino acids and added electrolytes for The field of pharmacogenomics has linked the role of
maintenance levels. Lipid emulsions supplementation three nutrition in gene expression.
INDICATIONS OF ENTERAL NUTRITION IN CRITICAL BURN The problem of overfeeding: The pathophysiology of burn
injury is complex and a dynamic process with many variables
PATIENTS: that make estimation of the nutritional requirements very
Reduced level of consciousness, impaired swallowing, difficult. The complication of overfeeding may occur
inadequate oral intake following institution of an aggressive nutrition therapy in
Impaired gastric emptying, gastric outlet obstruction early phase of postburn injury, as the metabolic rate slows and
Hepatic failure intestinal absorption improves. They are associated with
In patients with moderate intestinal failure, for maintaining complications such as fatty liver, azotemia, and
integrity of gut hyperglycemia that lead to difficulty in weaning the
For modulation of stress response. Systemic immune patient from ventilatory support. Due to overfeeding of
response modifications carbohydrates there is increased synthesis of fat and
Disease severity attenuation and to provide immune- carbon dioxide that result in elevation of respiratory
modulating agents quotient. There is worsening of respiratory status, and
Stress ulcer prophylaxis weaning from the ventilator is prolonged. There is
mobilization of all available substrates due to burn
Early enteral feed via gastric route is preferred in critical hypermetabolic response. Development of fatty liver
burn injury patients for the beneficial effects like attenuation results due to an increase in peripheral lipolysis.[90]
of the stress response, stress-induced ulcers and increased
production of immunoglobulin. Few factors in the initial Increased fat deposition in liver parenchyma occurs in
phase of resuscitation like use of larger amounts of overfeeding due to parenteral/ enteral route of nutrition
crystalloids, with edema of the intestine and paralytic ileus therapy and fatty liver leads dysfunction of immune
can prevent early start of enteral feeding. Enhanced capillary system and enhances mortality rates. Azotemia results
leak in the early phase of burns increases the fluid from excess protein supplementation in burn patients.
requirement. Prerenal kidney injury due to massive fluid shift of burn
injury results in increased level of blood urea nitrogen.
Enteral route nutrition support should be started immediately Patients with azotemia need close monitoring for signs of
(4–6 h) after large burn injury (>20% TBSA) [Table 7]. Early renal failure as it aggravates the stress on the kidney. If there
enteral feeding is safe and beneficial. Impact peptide 1.5 is no positive response to hydration therapy, reduce the
(formerly crucial) is the primary choice formula providing amount of protein in nutritional supplement. Patients with
high-nitrogen, peptide-based diet with supplemental arginine, renal failure must continue to get nutritional support. Blood
lipid as 50% MCT oil, vitamin C, vitamin A, and Zinc. Start chemistry is regularly monitored for any metabolic
Impact peptide 1.5 @ 20 mL/h and increase as tolerated up to derangement and necessary corrective measure taken.
the goal determined by dietitian. Impact peptide 1.5 is to be Formulas of nutritional needs are used as guidelines.
provided for 7 days and then substituted for a formula with Reassessment of energy requirements are done regularly.
added protein in consultation with dietitian. Do not continue Nutritional reassessment is done with standard equations and
with enteral nutrition if patient shows signs of abdominal injury/activity factors at the end of acute hypermetabolic
compartment syndrome with bladder pressure >20 mmHg. phase. This prevents the problems of overfeeding.
Enteral versus parenteral nutrition: The enteral nutrition Changing status of wounds, physical and occupational
whenever possible has many advantages over the parenteral therapy activities should be considered for estimating
route. Enteral nutrition helps to maintain the integrity of nutritional needs.
intestines. They support to keep the tight junctions
between intraepithelial cells. It also improves the intestinal
blood flow and stimulates secretion and release of SEPSIS AND ENTERAL FEEDING INTOLERANCE
cholecystokinin, gastric, bombesin, and bile salts. It also Diagnosis of early sepsis in burns patients is crucial for
maintains villous height and support IgA producing survival of patients. The American Burn Association
immunocytes. Within hours of major insult, intestinal guidelines for diagnosis of sepsis are based on many
permeability changes due to loss of functional integrity criteria. Confirmation of infection requires presence of at
thus increasing the risk and severity of infectious least three criteria:
complications.
Table 7: Basic guidelines regarding the route of feeding

Percentage of TBSA of burn Feeding approach
<20% without facial injury, inhalation injury, or Oral diet with high protein and high energy
malnutrition in preburn period
>20% TBSA burns Dietary intake during the dayNocturnal tube feeding to supplement intakeNutrient
analysis to ensure adequate intake
Fever more than 39°C or hypothermia with temperature less synthesis of glycogen, fat, and protein in cells. Fluid and
than <36.5°C electrolyte disorders that accompany the syndrome are
Increased heart rate greater than 110 beats/min reduction of serum concentrations of potassium, magnesium,
Increased respiratory rate with more than 25 breaths/min in and phosphorus. Hypophosphatemia is the most common and
non-ventilated patients dangerous, and the signs may mimic cardiac, pulmonary,
In ventilated patients with a minute ventilation of greater than neurological, neuromuscular, or hematologic symptoms.
12 L/min Severe persistent low serum mineral levels can be fatal.
Thrombocytopenia with less than 100,000/mL platelet count
Hyperglycemia, in the absence of preexisting diabetes
mellitus (untreated plasma glucose >200 mg/dL or >7 DURING FASTING THE FOLLOWING BODY CHANGES
units of insulin per hour intravenous drip or significant OCCUR:
resistance to insulin, >25% increase in insulin requirement (1) During fasting, tissue fatty acids and amino acids
over 24 h) become the main sources of energy instead of
Inability to continue enteral feedings >24 h (abdominal carbohydrates and fat.
distension or high gastric residuals, residuals two times (2) Conservation of red blood cells occurs as the spleen
feeding rate or uncontrollable diarrhea, >2500 mL/day). decreases its rate of red blood cell breakdown. Many
intracellular minerals become severely depleted during
Intolerance to enteral route feeding in sepsis adversely affects this period, in spite of the fact that the serum levels
patients’ nutritional status with increased morbidity and remain normal.
mortality. An increase in mean PCT level and a decrease (3) In fasting state, insulin secretion is suppressed and
in prealbumin level are other findings of burn sepsis.[91,92] glucagon secretion is increased.
Nutritional indicators of bacteremic sepsis: In burn patients
nutritional assessment parameters for sepsis are crucial for early During refeeding: Due to an increased blood sugar level,
detection and control of infection. Transferrin, serum albumin insulin secretion is restored. There is an associated increase in
and nitrogen balance values are monitored on postburn day 10. levels of glycogen, fat, and protein synthesis. These processes
Total lymphocyte count, skin test reactivity and percentage of require and use phosphates, magnesium, and potassium. As
ideal body weight (%IBW) are also taken into consideration. the electrolytes are already depleted, their stores are also used
The laboratory findings that predict an imminent septic episode up rapidly. The following changes occur during refeeding:
include: (1) Formation of phosphorylated carbohydrate compounds
estimated serum albumin levels <3.0 g/dL (P < 0.001), in the liver and skeletal muscle depletes intracellular
total lymphocyte count value of <1500/MM3 (P < 0.001), ATP and 2,3-diphosphoglycerate in red blood cells,
anergy (P < 0.001), and leading to cellular dysfunction and inadequate
estimated serum transferrin level <150 mg/dL (P < 0.01). oxygen delivery to the body’s organs.
(2) Refeeding increases the basal metabolic rate.
(3) Intracellular movement of electrolytes occurs along
FEATURES IN SEPTIC PATIENTS WITH FEEDING with a fall in the serum electrolytes, including
phosphorus and magnesium. Levels of serum glucose
INTOLERANCE: may rise and the B1 vitamin thiamine may fall.
Lower mean caloric intake is a characteristic feature. (4) Cardiac arrhythmias are the most common cause of
Ratio between PCT (procalcitonin, infection marker): death from refeeding syndrome, with other significant
prealbumin (nutrition status marker) is high. risks including confusion, coma, and convulsions and
Incidence of pneumonia is higher. cardiac failure.
Sequential organ failure assessment maximum score will be (5) Gastrointestinal disturbance like colicky abdominal
higher. pain, reflux symptoms, nausea, and early satiety occurs.
Inability to wean the patient from mechanical ventilation with
a need for prolonged period of ventilation. Treatment: The most common cause of death in refeeding
Septic patients with gastric feeding intolerance have a higher syndrome is abnormal cardiac rhythms. Blood biochemistry
mortality rate. monitoring must be done early in refeeding period so that the
underlying electrolyte imbalances can be corrected to avoid
Refeeding syndrome is metabolic disturbance syndrome. mortality.
Patients who are starved, severely malnourished, or (1) Phosphate levels drop to 0.65 mmol/L (2.0 mg/dL) from
metabolically stressed due to severe illness including burn previous normal level and if the drop happens within 3
injuries are prone for refeeding syndrome that develops on days of starting enteral or parenteral nutrition, it is an
starting of nutrition. Excess of food or liquid nutrition indication for electrolyte replacement therapy. It is
supplementation during the initial 4 to 7 days post-burn recommended to keep the caloric intake up to
period is the common cause of refeeding syndrome.[93,94] 480 kcal/day for at least 2 days during the period of
Characteristic feature of the condition is a trigger for electrolyte replacement therapy.
(2) Energy intake must be kept at a lower level than normal hypertension, high cholesterol, and associated coronary
requirement for the first 3–5 days of treatment of heart disease (CHD) is predicted with a waist
refeeding syndrome. circumference of >94 cm in men and >80 cm in women.
(3) Multivitamin, mineral supplements, thiamine and Waist to hip ratio predicts heart diseases and risk of mortality
vitamin B complex must be given at appropriate and has little advantage over waist circumference.
doses.[95]
Biochemical and hematological values have limited value
Individual markers of nutritional status: Anthropometry in assessment of nutritional status. Profound nutritional
is a good indicator of both health and nutritional status in depletion greatly alters the physiological chemistry. They
individuals. It measures individual size, shape, and are prone for changes on a daily basis and homeostatic
composition of human body and predicts health and mechanisms frequently try to compensate such changes.
survival. The common techniques are body weight, body These parameters are modified by disease conditions and
mass index, mid-arm muscle circumference, and skin fold nutritional status measurements are inaccurate. Estimations
thickness. Body weight is a measure of total weight including of vitamins, minerals, and trace elements show only
muscle, fat, water, and bone. Body weight alterations reflect depleted levels in severe nutrient deficiency, for
nutritional status and are an important assessment tool. example, iron, zinc.
Underweight as well as overweight status has an important Nutritional management considerations in pediatric
outcome in mortality and morbidity following burn injuries. patients: “Extensive thermal injury elicits the most
Body mass index (BMI) is weight of the person in kilograms profound response to stress that the human body is capable
divided by height in meter square. It is a measure of body fat of generating.”[96] Pediatric patients with critical burn injuries
stores, a useful tool to classify subjects into weight categories have increased nutritional requirements due to losses of
and its relationship to health risks. Muscle mass is not taken protein and trace elements through wound exudation.
into account in calculation of body mass index. It is not ideal Repeated episodes of fasting for surgical procedures and
for children. Their weight needs to be monitored using dressing changes, pain and nausea make pediatric burn
growth charts. patients nutritionally more vulnerable. Psychological
Growth charts: Adequacy of nutritional status in infants and distress in children and side effects of medication also
children can be studied using anthropometric methods. modify nutrition in children. The top priority in children
Adequate growth is the single most important measure of and adolescents with burn injuries is to achieve normal
nutritional status in infants and children under 5 years old. growth and development. Protein, energy, vitamins and
Weight for age, height for age, and weight for height minerals supplementation in adequate quantities is crucial
calculation are used to identify the presence of under to good wound healing, to reduce risk of infections,
nutrition in children. breakdown of wounds and grafts. Adequate nutrition
Height for age is the measure of linear growth; growth reduces respiratory complications and shortens hospital
failures of long duration or stunting are measured. stay duration and make sure the child maintains a normal
Weight for height is sensitive factor in acute growth growth.
disturbances. It reflects development of proper body
proportions and associated harmony of growth. It helps in BURN MANAGEMENT IN CHILDREN AND ADULTS—KEY
detecting wasting. POINTS:
Weight for age is for identification of underweight children.
Children require more fluid than adults as fluid losses are
Various standards are compared to international reference higher in children. Also, they have nearly three times the body
standard populations by NCHS/WHO (National Centre for surface area (BSA) to body mass ratio compared to adults.
Health Statistics/World Health Organization). To be High surface-to-volume ratio and low-fat mass in children
classified with wasting, underweight or stunting, the child make them prone to develop hypothermia that increases the
must be 2 SD or more below the compared standards. risk of increasing the depth burn and hypothermia must be
avoided.
Skin fold thickness is a simple test to study the relationship Adequate fluid resuscitation, prevention of hypothermia, pain
between subcutaneous fat and total body fat. Yuhasz skinfold control, and optimal blood glucose level must be the goal in
test uses six sites for measurements. Most other tests use only pediatric burn patients.[97]
three or four sites. Pinch a fold of skin with subcutaneous fat Further increases in metabolic rate are due to non-shivering
between a pair of skinfold calipers and measure the thickness thermogenesis of temperature regulation.
(adiposity). The common areas of skinfold measurements are Urinary output is the most reliable and sensitive indicator of
triceps, abdominal, chest wall, midaxillary, subscapular, fluid resuscitation in children and fluid resuscitation must be
suprailiac and thighs. Waist circumference is an more precise.
important tool in the classification of obesity and predicts Pain management in burn injured children is crucial for
risk of obesity formation. It is an accurate measure of central hemodynamic stability and nutritional therapy. Children
obesity. Increased risk of diseases like Type 2 diabetes, cannot express pain. It is safer to start with small doses of
Table 8: Calculation of energy requirements in larger burn in children

Formula name Age group Calculation formula
Galveston infant formula 0–12 months 2100 kcal/m2 BSA + 1000 kcal/m2 BSAB
Revised Galveston 1–11 years 1800 kcal/m2 BSA + 1300 kcal/m2 BSAB
Galveston adolescent 12–18 years 1500 kcal/m2 BSA + 1500 kcal/m2 BSAB
Table 9: Energy calculation based on TBSA Table 10: Protein requirement based on age group
Age group Formula Age group Recommended protein intake
2
0–12 (2100 kcal × TBSA [m ]) + (1000 kcal × BSA burned 0–12 months Use reference nutrient intake (RNI) for age
months [m2]) 1–3 years 2–3 g protein/kg/day needed to achieve wound healing
1–12 years 1800 kcal × TBSA [m2]) + (1300 kcal × BSA burned 3–18 years 1.5–2.5 g protein/kg/day
[m2])
2
12–18 years 1500 kcal × TBSA [m ]) + (1500 kcal × BSA burned
[m2])
Hildreth equation: TBSA can be calculated using the
surface area nomogram or the following formula
[Table 9]: Total Body Surface Area = Height
Morphine at 0.1 mg/kg body weight by intravenous route (cm) × weight (kg)/3600. TBSA is then used to calculate
and the dosage can be increased based on hemodynamic individual energy requirements.
stability and assessment of respiratory status.
Protein requirements for minor burns: Normal protein
requirements for age are sufficient for patients with minor
THE AIMS OF NUTRITIONAL INTERVENTION FOR
burn injuries. Protein requirements are higher in the
PEDIATRIC BURN INJURED PATIENTS ARE: moderate/major burn patients.[99]
Attain normal growth and development especially in children. There is a massive protein loss through burns exudates.
Maintain lean body mass. Protein is needed for skin repair so requirement is high
Optimize wound healing process and good take of skin [Table 10].
graft.[98] Burn injury is associated with deterioration in nutritional
Modulation of immune system. status of patients admitted to the hospitals. Moderate and
Correction of preexisting nutritional deficiencies. severe malnutrition is seen in 20% of the patients within the
Integrity of gut and bowel function must be maintained. two weeks following burn injury (weight for height scores).
About a third of the patients lost more than 10% of their
Energy requirements in children: Indirect calorimetry is weight in two weeks, a very rapid weight loss compared to
ideal for estimation of energy requirements in pediatric burn what is expected in pediatric burn injury patients.
patients. Assessment is done on hospitalization and then Age and preburn nutritional status have a significant role in
twice weekly till the wounds are all healed. The total deterioration of nutritional status in pediatric burn patients.
energy needed is calculated by RMR multiplied by a Growth deficiencies can be identified by using tools like mid-
factor of 1.3 (20%–30%). For patients with <30% TBSA upper arm circumference measurement.
burn, adequate energy is provided by using dietary reference
intakes (DRI) initially according to the age group. For greater Baseline blood measurement of nutritional elements (U
than 30% TBSA burns following formula is used [Table 8] and E) to detect abnormalities of blood chemistry, primarily
(BSA—body surface area: BSAB—body surface area renal function and hydration are done. Serum albumin, CRP,
burned). liver function tests, FBC, phosphate, calcium, vitamin D, and
magnesium are the basic investigations required. Patients
Energy requirements are calculated depending on age,
suffering from moderate and severe burn injuries must
weight, and height, TBSA burn injury and depth of
check trace element status on a weekly basis until return
thermal injury. Burn dietitian calculates the requirement
to normal range.[99]
and must continually reassess the therapy. In the first 24 h
following injury, energy requirements does not rise above Nonprotein calorie to nitrogen (NPC:N) ratio: Ideally
the estimated average requirement (EAR). Estimated NPC:N ratio should at 150:1 for small area burns and
average nutritional requirement can be achieved easily in 100:1 for larger area burns. Calculation of nonprotein
patients with smaller percentage of burns. For children, use kcalories to nitrogen ratio (NPC:N):
the EAR for their age and weight. For children with burns (1) Total nitrogen in grams supplied per day is calculated (1
>10%–15% body surface area, the Hildreth formula is gN = 6.25 g protein).
currently the standard formula used for calculating energy (2) Total nonprotein kcalories is divided by grams of
requirements. nitrogen.
Table 11: NPC:N ratio to be maintained in children with burn injuries

<1% TBSAB 3–4 g/kg of proteins
1%–10% TBSAB 15% of total energy or nonprotein calories to nitrogen ratio (NPC:N) of 150:1
>10% TBSAB 20% of total energy or NPC:N of 100:1
NPC: N Calculation example: 80 grams protein - 2250 in pediatric patients in the postburn follow-up visits. Both
nonprotein kcalories per day. 80 g protein/6.25 = 12.82250/ vitamins D3 and D2 (100 IU/kg) supplementation help
12.8 = 176 NPC:N = 176:1. critically ill pediatric burn patients to sustain growth.
Enteral feeds in pediatric burn patients: In the presence of
DESIRABLE NPC: N RATIOS VALUES [TABLE 11]: functioning or even partially functioning gastrointestinal
In the most severely stressed patients at 80:1 tracts enteral feeding is the route of choice for the
In severely stressed patients at 100:1 nutritional support in pediatric burn injury patients. Enteral
Unstressed patient at 150:1 feeds and supplementscontain additional vitamins and
minerals, and this may be sufficient to meet the child’s
Micronutrients supplementation in pediatric burns: increased requirements with out the need for
Antioxidantvitamins like A, C, and E and trace elements supplementation. Children with major burn injuries need
beneficial effects on wound healing and immunity.[101] Trace protein and energy (calories) requirements 2–3 times
elements are mostly lost through large volume exudates in normal and the requirements for vitamins and minerals are
burn wounds. Micro-nutrients cannot be synthesized in the also increased.
body and decreased levels are identified in the postburn
injury.[102] Various metabolic activities such as oxidative
stress, collagen cross linking in wound healing, and FOLLOWING ARE THE REASONS FOR FAILURE TO EAT
immune functions are related to presence of many ENOUGH BY CHILDREN WITH BURN INJURIES:
enzymes. Micronutrients and trace elements are important
(1) The shock and trauma of the burn
components of most enzymes.
(2) Drowsiness from drugs, fever, pain, and fear
It is recommended trace elements administered immediately (3) Related to burn washing and dressing
within the first few hours following burn injury (Berger). (4) The hours of fasting for baths and graft operations
High dose of trace elements supplementation reduces the (5) Time spent in physiotherapy or at other appointments
length of hospital stay, infection rates, and reduces the (6) Being in hospital itself in unfamiliar surroundings and
number of graft procedures required and supports wound with unfamiliar foods
healing. ESPEN recommends administration of trace
elements in higher doses in postburn periods.[103] Special attention must be focused on children to meet with
Depending on TBSA of burn, trace elements should be their nutritional needs. It is difficult to manage children
prescribed for particular duration. during the nutritional supplementation period; they need to
20%–40% burn injury—for 7–8 days eat and drink more to make up for the increased energy and
40%–60% burn injury—for 2 weeks protein needs. Dietitian advises on the best feeding plan for
>60% burn injury—for 30 days the inpatient child. Discussion with the dietitian and nursing
staff regarding the various aspects of nutrition issues with the
child will help mothers to continue the treatment at home.
Calcium and vitamin D requirements in pediatric burn
patients: Major burn injuries in children cause dysfunction of Guidelines to encourage children with burn injuries to eat
calcium and vitamin D homeostasis mechanisms. It is and drink include are as follows:
associated with osteoblast apoptosis—an increase in bone Well-planned healthy food must be given to all throughout the
resorption and urinary calcium wasting. Synthesis of normal day. Ideally, small and frequent amounts of food must be
quantities of vitamin D3 is not possible in the burnt skin, and this given, aim for 5–6 small meals or snacks each day.
decreases the levels of calcium and vitamin D. Homeostasis of Food that is familiar to the child must be given and encourage
calcium, phosphorus, and skeletal bone integrity depends on foods that the child can manage.
vitamin D levels and also has significant metabolic effects on Home-cooked meals and the child’s favorite foods supplied
serum calcium, magnesium, and phosphorus. Almost 97% of from home will be accepted better.
pediatric age group burn injury patients have low vitamin D For babies and toddlers, milk and nutritious drinks are very
(serum 25-hydroxyvitamin D) levels at 1 year following important. Plan them during each meal and snack times,
major burn injuries. Administration of vitamin D3 beyond especially when children are not eating much.
the acute phase of burn corrects the abnormal serum levels and Take help from the dietitian regarding the best choice for the
avoids morbidity. Vitamin D3 reduces the risk of postdischarge child. A positive attitude when offering food and drink to the
fractures in children. It is important to monitor the bone health child will make them accept food better.
Table 12: Enteral feed formula available for enteral nutrition

Age group Type of feed Energy kcal/100 mL Protein g/100 mL
0–12 months Expressed breast milk or infant formula may require 67 kcal/ 100 mLCan be increased with Approx. 1.3 g/100 mL
fortification fortification
0–12 months High energy infant formula SMA high energy infatrini 91 kcal/100 mL100 kcal/100 mL 2 g/100 mL2.6 g/100
mL
1–6 years Nutrini (MF)Nutrini energy (MF) 100 kcal/100 mL150 kcal/100 mL 2.8 g/100 mL4.0 g/100
(8–20 kg) mL
>7 years Tentrini (MF)Tentrini energy (MF) 100 kcal/100 mL150 kcal/100 mL 3.3 g/100 mL4.9 g/100
(20–45 kg) mL
>45 kg Nutrison (MF)Nutrison energy (MF) 100 kcal/100 mL150 kcal/100 mL 4.0 g/100 mL6.0 g/100
mL
Table 13: General progression of intravenous fat emulsions

1. Pro-inflammatory First generation 100% SO
2. Inflammatory neutral Second generation 50:50 MCT:SO
Third generation OO containing products
3 Anti-Inflammatory Fourth generation FO containing products
SO = Soya oil; OO = olive oil; MCT = medium-chain triglyceride; FO = fish oil.
Positive praise, no matter how small as your child eats or with their situation. Dysfunctional behaviors or attitudes
drinks will encourage to take more. also develop in children, and they must deal with a lot of
Make enjoyable and interactive for your child during meal complications. They develop anxiety and post-traumatic
and snack times. stress disorder (PTSD) symptoms. They develope difficulty
with social interaction, issues related to self-esteem, or
KEY POINTS: problems with body image due to scarring and functional
deficits as a result of the burn injury. Negative psychosocial
Tentrini range is not on the starter regime, choose Nutrini up
outcomes are common in nearly 15%–20% of children as a
to 21 kg and Nutrison if >21 kg. MF = multifiber. Most feeds
result of burn trauma. Pediatric survivors and their families of
are available with or without fiber. All the earlier feeds
burn injury require professional psychological support to
contain cow’s milk protein. Check for any allergies before
recover from the burn-related psychological
commencing a feed [Table 12].
problems.[104,105]
If the child is on a specialized formula, the child seeks dietetic
advice for patients with major burns and an additional protein
may be provided by a supplement or specialized feed. If a UNIQUE CONSIDERATIONS IN PEDIATRIC BURN CARE—
patient is also receiving larger than normal volumes of feed in
order to meet higher calorie requirements, it may be necessary KEY POINTS:
to review electrolyte content. Children with partial-thickness burns of greater than 10%
A feed that is designed for a younger age group (e.g., Tentrini TBSA, burns of the face with or without inhalation injury
range, instead of Nutrison) may be needed to avoid excess must be referred and treated in a burn care facility. The other
electrolytes. indications include burns involving head, neck, hands, feet,
Micronutrients content should be reviewed and compared to genitalia, or electrical or chemical burn injuries. Burn center
reference nutrient intakes (RNIs) if excessive feed volumes or referral criteria for pediatric patients include intentional
inappropriate for age feed is being provided. injury and suspected child abuse.
It is a good practice to regularly monitor for signs of gastric Children have limited physiological reserve, and fluid
intolerance when a patient is receiving enteral nutrition. resuscitation has to be precise. Lund–Browder chart is
A hydrolyzed feed may be indicated if a whole protein feed is used to estimate TBSA and fluid is calculated at 2 mL
not tolerated. times percent of TBSA times weight in kilograms.
Estimation of pediatric energy expenditure is done with
Psychological support in pediatric burn patients: In acute Schofield equation.
phase, psychological stress often accompanies the physical Children have small airways and with little suspicion of
damage of severe burn injury. Children are prone to develop inhalation injury they must be intubated immediately using
internalizing behavioral changes such as anxiety and a low-volume cuffed endotracheal tube.
withdrawal. They may develop externalizing behaviors Adequate sedation and analgesia for dressing changes reduce
characterized by oppositional defiant disorder. They are pain and psychological trauma.
the healthy coping mechanisms that help children deal Institution of nutrition therapy at an early period is essential.
Table 14: Different methods of administration of parenteral nutrition

Total parenteral nutrition (TPN) or total nutrient admixture (TNA) No significant nutrition received by other routes
Partial parenteral nutrition (PPN) Patient receives nutrition partially by enteric route also
Peripheral parenteral nutrition (PPN) Venous access administration in a limb
Central venous nutrition (CVN) Nutrition administered through a central vein
Table 15: The recommendations for parental nutrition Table 16: Total parenteral nutrition solutions and their
Carbohydrate composition
Adult burn Glucose infusion rate (GIR) at 3–4 mg/kg/min.
Substance/fluid Normal patient High stress Fluid restricted
patients Provides 50%–60% of total energy requirements Amino acids 85 g 128 g 75 g
in critically ill burn patients. Insulin is used to Dextrose 250 g 350 g 250 g
maintain normoglycemia
Lipids 100 g 100 g 50 g
Children with burn GIR at 7–8 mg/kg/min and increase as needed to
Na+ 150 mEq 155 mEq 80 mEq
injuries a maximum of 20% dextrose solution
K+ 80 mEq 80 mEq 40 mEq
Infants with burn Initiate dextrose infusion at 5 mg/kg/min and
injury increase to 15 mg/kg/min over a 2-day period. Ca2+ 360 mg 360 mg 180 mg
Fat Mg2+ 240 mg 240 mg 120 mg
Adult burn patient 10%–30% of total energy in critical care is Acetate 72 mEq 226 mEq 134 mEq
achieved with 2%–4% as essential fatty acids and Cl− 143 mEq 145 mEq 70 mEq
to prevent deficiency P 310 mg 465 mg 233 mg
Children >1 year 30%–40% of total energy from fat sources MVI-12 10 mL 10 mL 10 mL
Children <1 year Up to 50% of total energy from fat sources MVI- 5 mL 5 mL 5 mL
MVI-12, multi-vitamin infusion without vitamin K.
Physiologic and psychosocial problems in children are translocation, should be given where possible.[107]
different from adults. Approximately 50% of total energy should be from
carbohydrates sources for all burn patients. The
Child psychiatry, child life specialist, and therapists will help recommendations shown in Table 14 are made in
cope up with the situation. Counseling is required for the relation to the age group of the patients.
child, caretakers, and family members. Total parenteral solutions are available in different
composition of its constituent nutrients content. Both
Parenteral nutrition (PN) is the intravenous route of clinical and laboratory monitoring are important in
feeding. It does not involve the natural process of eating deciding about the type of the required supplementation
and digestion, although it bypasses the gastrointestinal tract [Table 16].
[Table 13]. Ideal candidates for parenteral nutrition are
patients at risk of malnutrition with depleted reserves and
who fail to achieve required nutrition by oral or enteral routes.
INVESTIGATIONS TO BE DONE IN PATIENTS WHO ARE
Nutritional formulae are available with glucose, salts, amino RECEIVING TPN:
acids, lipids, with added vitamins, and dietary minerals in Blood glucose monitoring every 4–6th hourly.
various combinations and proportions. It can be short-term or Assessment for the risk of refeeding syndrome must be done
long-term parenteran nutrition. The TPN may be avoided as daily.
many patients receiving parental nutrition (PN) will continue Transferrin and C-reactive protein (CRP) estimation should
some level of oral intake. be done once or twice weekly.
PN is instituted in consultation with the multidisciplinary Evaluation of liver function, lipid profile, and calcium along
team when EN is contraindicated or the patient is not able to with an estimation of albumin and prealbumin values must be
meet the needs due to ileus, small bowel obstruction, done on weekly twice basis.
prolonged malabsorption, or intolerance to EN.[106] There Estimate serum levels of zinc, iron, selenium, and copper
are different approaches to implementation of PN levels every 2–4 weeks.
[Table 14]. Complications of PN are metabolic or Full blood count and serum magnesium and phosphate levels
catheter related. Skin loss and thrombotic complications estimation. Manganese and 25 OH vitamin D levels should be
carry significant mortality. done at 3–6 monthly intervals.
Patients requiring PN should be referred to dietitian for Complications: TPN predisposes to various complications as
recommendations regarding nutritional supplementation it entirely bypasses the gastrointestinal tract and natural ways
[Table 15]. Provision of trophic feeds maintains of nutrient absorption: Infection: Approximately 15% of
integrity of the gut and also reduces bacterial patients get infective complications due to TPN and death
is due to septic shock. Infected chronic intravenous access

catheter is a common cause of death. Hospital-acquired
infection (HAI) is a major complication of PN and every
effort should be made to avoid HAI. Blood clots: Chronic IV
access leads to thrombus formation and may develop
pulmonary embolism leading to death. Fatty liver and
liver failure: Linoleic acid is an omega-6 fatty acid
component of soybean oil, a rich source for calories. It
causes fatty liver and lead to liver failure. Hunger:
Patients on TPN develop intense hunger pangs as they are
not eating, even though the body is getting fully nourished.
Cholecystitis: Complete disuse of gastrointestinal tract
results in bile stasis in gallbladder and formation of sludge
that takes 4 weeks to disappear after starting normal oral diet.
Risk of acute cholecystitis occurs. Exogenous
cholecystokinin (CCK) and amino acids prevent sludge
formation. Steatohepatitis, steatosis, cholestasis, and
cholelithiasis are the various hepatobiliary dysfunctions Figure 4: Algorithm for management of nasogastric feeding
that are common. Gut atrophy is common in patients on
Gastric residual volume (GRV) is an important measure in
TPN and are not taking food by mouth for prolonged periods
patients on continuous feeding protocols. It should be
of time. Other complications are related to catheter or
checked every 4–8 h as a routine and before start of each
metabolic causes. Catheter insertion has risk of
intermittent feeding.
pneumothorax, accidental arterial puncture, and catheter-
When GRV reading is greater than 200 mL, it indicates a
related sepsis. Hypophosphatemia, hypokalemia, and
careful bedside evaluation to be done immediately.
hypomagnesemia of refeeding syndrome are the main
Adjustments in appropriate feeding method and feeding
metabolic-related complications. Hyperglycemia occurs
volume are necessary.
with abrupt cessation of TPN.
Abdominal distension, absence of bowel sounds, and the
presence of nausea and vomiting are the clinical
Role of nursing staff in nutrition of burn patients: Nursing
examinations required. With increased GRV levels a
personnel play a central role in wide spectrum
change in feeding strategies must be planned.
multidisciplinary care of burn injury patients. Their role
A series of GRV is more important and informative than an
begins with the resuscitation of the patient and proceeds
isolated high level of GRV.
through various stages of recovery of the patient. They
Returning and not returning gastric residuals do not show
coordinate with various departments and specialties for the
significant differences between them.
benefit of the patient. They take part in infection control and
care of the wound. They identify and take care of nutritional
care of burn injured patients. Insertion and stabilization of NURSING INTERVENTIONS—KEY POINTS:
NGT, monitoring the pH, feeding tube placement check by Nasogastric tube for gastric decompression is essential in
radiology, check tube clogging, and tube patency patients with greater than 20% TBSA burns.
maintenance protocols are responsibilities of nursing staff Abdominal girth measurements and bowel sounds are
[Figure 4]. pH checking: Correct tube placement in the checked every 8 h.
stomach is confirmed by appearance of aspirate and pH Color, quantity, and pH of NG aspirate is checked and
testing. Confirm a position of feeding tube by radiology monitors stool for hemocult blood.
when appearance of the aspirate is not suggestive of gastric or Stress ulcer prophylaxis is an important consideration.
intestinal origin or has a pH between 5 and 6 and when Enteral feeding is initiated and evaluates the tolerance to the
aspirate fluid pH is >6 with no aspirate despite other feeds.
measures. Feeding position: The nursing staff make sure High-calorie/protein supplements are used as advised by
the position of the patient during feeding. During feeding dietician.
procedure, it is recommended to keep a semirecumbent Record of all oral intake and calories administered must be
position or an elevation of at least 30 degrees. Maintaining documented.
the position for at least 1 h after feedings to prevent Activities and interventions must be scheduled in such a way
complications of aspiration is required. The speed and as not to avoid interrupting feeding schedules.
volume of feeding affect intragastric pressure and develop Weight measurements of the patient are done on a daily or
gastroesophageal reflux (GER). Administration of biweekly protocol followed in the burn center.
medications, prevention of diarrhea, and monitoring and
management of gastrointestinal tolerance are important Percutaneous endoscopic gastrostomy (PEG) tube:
role played by the nursing staff. Alimentation and decompression are the two important
aspects of a successful management of nuitrition in severely therapy and good psychological counseling will support
burned patients. The aim is to maintain their caloric balance. the patient get back to his job and to the society.
Conventionally used NGT causes discomfort and other
Burn rehabilitation: The aim of treatment of burn patients is
complications. In nonburn patients in ICU, PEG has been
to obtain an excellent functional recovery. From the day of
used successfully for nutritional access. In patients with
burn it undertakes rigorous program to protect range of
associated inhalation injury or dysphagia, PEG tubes are
motion (ROM), strength, and flexibility. Preservation of
used as nutritional portal. Tube placement through partial or
ROM and skin integrity are the goals of the initial
full-thickness burn areas does not have an increase in wound
rehabilitation phase. A treatment plan based on patient’s
complications. The advantages of PEG tubes are that feedings
individual needs is developed by a burn care therapist.
are tolerated well, and no major operative or wound
Physical and occupational therapy started from the acute
complications with no mortality related to the tubes. A
phase of burn injury is ideal.[109] Patients must aim to
modified tube with two exchangeable lumens of sufficient
maximize performance in ambulation and mobility. They
diameter has improved performance of feeding. It has been
must aim to achieve in activities of daily living, that is,
introduced exclusively for use in burn patients.
bathing, dressing, and return to community activities as
Challenging aspects of burn nutrition are nonavailability of early as possible. Splinting and positioning regimes
indirect calorimetry. Present challenges and possible include supporting strategies such as regular and
measures that can be taken in developing countries include preemptive analgesia. Children require play therapies,
making them available. Biomarkers of illness can improve in distraction techniques, and rewards (i.e., sticker charts) for
molecular basis of different pathological conditions. improving their performance. Ongoing education, positive
Extensive search is needed in the field of glycemic reinforcement, and consistency in care of the patients are the
control, pharmaco-nutrition, and immune-nutrition. There essential components for good outcomes and early
is a need to carry out randomized control trials and studies rehabilitation of burn injury patients. Splinting and
to make guidelines, improve “total burn care” concept, and positioning regime issues are recorded and reported back
improve funds that are available for health services. to physiotherapy and occupational therapy for required
alterations to regimes to be initiated. The nursing staffs
Nutrition management after discharge: It is mandatory that coordinate with the entire burn care team ahd help in
the patients must continue with adequate nutrition therapy rehabilitation of patients with burn injuries.
program following discharge from the hospital. It is important
to maintain the benefits of nutrition therapy gained during “Quality of life” in burn injury patients: The final outcome
hospitalization. Hypermetabolic state persists more than a of burn management depends on various factors such as
year or two following burn injury. Diets with high protein severity of burn injury, individual physical characteristics,
and more caloric are necessary for about a year after and quality of treatment received. Motivation on part of the
discharge.[108] Resistance exercises are essential to patient and after care support received both from the family
maintain muscle mass and increase the strength. Physicians and community are also important factors. Physical and
and dietician advise the patients regarding the nutrition psychiatric morbidity depends on various factors such as
therapy to be followed at home. They must regularly severity of burn injury, treatment duration, surgical
check weight to make sure they maintain their weight. procedures, and associated pain. These factors are
Oxandrolone must be continued in the outpatient setting. important for morbidity in patients and may affect the
The optimum duration of such therapy is still a matter of quality of life in burn injury patients. Depression is the
discussion. Nutritional assessment is a routine and a valuable most common psychological problem and PTSD is also
exercise for follow-up patients. seen in large percentage of patients. Patients may suffer
from adjustment disorders, phobic anxiety disorder, acute
Burn nutrition in a nutshell: (1) EN started within 24–48 h stress reaction, substance use disorder, and somatoform
of burn injury has many beneficial effects on final outcome in disorders. Psychiatric care must be initiated at every stage
patients and the method of choice. (2) Energy requirements of their burn treatment. This will be beneficial for better
are elevated and must be supplemented, but overfeeding is adjustment in life and may require years of supervised
detrimental. (3) Administer proteins at 1.5–2.5 g/kg and rehabilitation, reconstruction, and psychosocial support.
maintain nitrogen: nonprotein energy ratio at 100:1. (4) Quality of life scale (QOLS) is measured by long-term
Arginine is used for a short period and not for long-term results in relation to function and appearance.[110] It
use. (5) Glutamine must be substituted for its positive effects measures three conceptual domains of quality of life, namely:
on the patients. (6) The need for micronutrients is also (1) Relationships and material wellbeing
increased and uses parenteral route for trace elements (2) Personal, social, and community commitment
replacement. (7) High-dose vitamin C administered in the (3) Health and functioning
initial fluid resuscitation phase helps reduce the volume of
fluid requirements. (8) Every stage of patient care must be “Recent updates in critical care nutrition—challenges and
monitored and corrective steps must be taken early. (9) solutions”: Nanotechnology has enhanced the potentials in
Progressive exercise program along with occupational research areas in nutrition: (1) Nanotechnology has helped in
discovery of novel properties nutrients. (2) Characterization genes and food bioactive compounds. Their interactions can
of properties of nutrients and their metabolites is made positively or negatively influence an individual’s health.
possible and nanotechnology has helped to quantify them. “Nutrigenomics” is an assessment of the interaction
(3) It is possible to assess nutritional status by between genes and nutrients.[116] Nutrigenomics is the
nanotechnology techniques and to target cells and study on the effects of the nutrients over the genome,
compartments. (4) Nanotechnology-enabled targetted proteome, and metabolome. Metabolomics is a
delivery of nutrients into cells and compartments have “systematic study of the unique chemical fingerprints that
been developed. (5) New devices and hybrid structures are specific cellular processes leave behind.” The chemical
developed for pathway repairs by nanotechnology. process involving metabolites is called metabolomics. It is
Prevention and cure of nutrient deficiencies are in a more a study of small molecule metabolite profiles. Collection of
quantitative and timely fashion. (6) Possibilities to explore all metabolites occurs in a biological cell, tissue, organ, or
epigenetic studies have opened up. A special emphasis on organism. They represent the end products of cellular
methylation and folate and one-carbon metabolism is made processes. The set of gene products being produced in cell,
possible by nanotechnology. (7) Critical cell nutrient which represents one aspect of cellular function, is confirmed
signaling pathways are identified and it is possible to by mRNA gene expression data and proteomic analyses
examine nutrients/metabolites as they modulate cell studies.[117] Easy identification and study of the physiology
signaling pathways. (9) Effect of cell nutrient signaling on of cell is possible by metabolic profiling. For better
overall cell function can now be analyzed by the available understanding of cellular biology, proteomic,
nanotechnology methods.[111,112] transcriptomic, and metabolomic informations must be
integrated which is a challenge in systems biology and
Nutritional Biomarkers are defined by Potischman as “any
functional genomics. Nutrigenomics is the integrated
biological specimen that is an indicator of nutritional status
study and links genomics, transcriptomics, proteomics, and
with respect to intake or metabolism of dietary constituents.”
metabolomics to human nutrition. Many factors may
It can be biochemical, functional, or clinical index of status of
influence metabolome. They are endogenous factors such
an essential nutrient or another dietary constituent. They are
as age, sex, body composition, and genetics; underlying
divided into three main classes, depending on the relationship
pathology and exogenous factors that can modify are diet
between intake and biomarker:
and drugs. Metabolic fingerprint is the biological end point
Recovery biomarkers development is based on
decided by nutrients, nonnutrients, and metabolomics from
physiological balance between intake and excretion. Total
the main diet. Large bowel microflora may act as endogenous
excretion of the marker over a defined time period is
or exogenous factor since it is a confounder of metabolic
measured. They are best suited to estimate absolute intake.
profiles.
Urinary nitrogen and potassium are the recovery markers
available.
Concentration markers are based on the concentration of DISCUSSION AND CONCLUSION
the respective marker. There is no information on the Burn care outcomes are variable due to multiple factors.
physiological balance of intake and excretion. As they Nutritional therapy affects the final outcome of burn care
correlate with intake, they are used to rank intake of in relation to mortality and morbidity. Administration of
specific nutrients. nutrients starting from the early resuscitation period proves
Predictive biomarkers were proposed by Tasevska et al. for beneficial to the patient. Best results are achieved with early
biomarkers with incomplete recovery. They are stable and EN that modifies and attenuates the hypermetabolic,
time-dependent high correlation with intake. These markers hypercatabolic state in burn patients. Macronutrients are
rank between concentration and recovery markers. They supplemented in a ratio of protein: carbohydrate: Lipids
have an ability to estimate absolute intake. Urinary sucrose 25:50:25. Glutamine administration at doses of 0.3–0.5 g/
and fructose markers of sugar intake are the only predictive kg and omega-3 fatty acids are beneficial for development of
biomarker available.[113,114] immunity. They decrease the inflammatory response and
prevent essential fatty acid deficiencies. Omega-6 fatty
Future research: Nutritional biomarkers provide an acids, when provided in large quantities, act as pro-
objective assessment method for dietary exposure. They inflammatory agent. Protein as a macronutrient has
are important for future research into the association beneficial effects and glutamine is the amino acid of
between diet and health. Development of new markers for choice. Antioxidants can be given enterally and
the objective assessment of fruit and vegetable intake is parenterally for their beneficial effects. Vitamins C and E
underway. Metabolomics is a new technology for decrease lipid peroxidation and improves wound healing.
development of new biomarkers. New biomarkers must be Zinc helps in recovery process following a burn. Selenium
validated using carefully controlled dietary intervention functions as activating glutathione peroxidase that is crucial
studies, and not just based on self-reported dietary in burn patients. Early EN with adequate supplementation of
data.[115] From nutrition to nutrigenomics: Human macronutrients, micronutrients, amino acid vitamins,
Genome Project (HGP) is the study of interaction between antioxidants, and trace elements help in good wound
healing and improved immunity and help in decreasing 12. The Acute Respiratory Distress Syndrome Network, Brower RG,
mortality and morbidity in critical burn injury patients. Matthay MA, Morris A, Schoenfeld D, Thompson BT, et al.
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Recent Concepts in Nutritional Therapy in Critically Ill Burn

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Recent Concepts in Nutritional Therapy in Critically Ill Burn

INTRODUCTION better antibiotics, nanotechnology-based dressing materials,

For reprints contact: reprints@medknow.com

DOI: How to cite this article: Natarajan M. Recent Concepts in Nutritional

Natarajan: Nutrition in critically ill burn patients

Table 1: Grade of recommendation, assessment, development, and evaluation

Natarajan: Nutrition in critically ill burn patients

HYPERMETABOLIC STATE IN BURN INJURIES

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Figure 2: Effect of burn wound on functions of various organs

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Figure 3: Metabolic pathways of carbohydrate, protein, and fat

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Table 5: Micronutrient requirements in critical burn patients

Natarajan: Nutrition in critically ill burn patients

Table 6: Classification of immunonutrient and their functions

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Table 7: Basic guidelines regarding the route of feeding

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Table 8: Calculation of energy requirements in larger burn in children

Natarajan: Nutrition in critically ill burn patients

Table 11: NPC:N ratio to be maintained in children with burn injuries

Natarajan: Nutrition in critically ill burn patients

Table 12: Enteral feed formula available for enteral nutrition

Table 13: General progression of intravenous fat emulsions

Natarajan: Nutrition in critically ill burn patients

Table 14: Different methods of administration of parenteral nutrition

Natarajan: Nutrition in critically ill burn patients

is due to septic shock. Infected chronic intravenous access

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

Natarajan: Nutrition in critically ill burn patients

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