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Leny Budhi Harti, S.Gz, M.Si.Med

Nutrition Department,
Faculty of Medicine
University of Brawijaya
Malang
Ferbuary, 2018

Medical Nutrition Therapy for Burns

 Contents

1 Metabolic Changes in Burns

2 Nutrition Management for Burns

3 Nutrition Care Process

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 Burns

• Burns are a result of tissue injury caused by exposure to heat,

chemicals, radiation, or electricity.
• The depth of the wound and the percentage of the body
surface area that is affected are used to classify burn injury

Nelms M., et al. 2010. Nutrition Therapy and Pathophysiology 2. Wadsworth, Cengage Learning 3
 Categories And Causes Of Thermal Injury
Category of Thermal Injury Cause
Chemical Cement, cleaning agents
Contact Radiators, cookers, iron
Electrical Domestic/industrial current
Flame House fire, bonfires, road traffic accidents
Flash Flammables, high voltages electricity
Friction Road traffic accidents, rope burn
Radiation Sunburn, radiotherapy, nuclear spills
Scalds Steam, hot fat

Adapted from Molyneux (2004) from Manual of Dietetic Practice Book

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 The Depth Of The Wound

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L. Kathleen, M, Sylvia, E.S, Janice, L. R, (2008). Krause’s Food and the Nutrition Care Process. 12th edition, International Edition. USA, Elsevier Saunders
 Grade I

Women’s and Children’s Hospital, Burns Database 2007

Royal Adelaide Hospital, Medical Art and Design

Grade II

Royal Adelaide Hospital, Medical Art and Design

Women’s and Children’s Hospital, Burns Database 2007

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 Grade II
Mild Dermal

Women’s and Children’s Hospital, Burns Database 2007

Royal Adelaide Hospital, Medical Art and Design

Grade II
Deep Dermal

Royal Adelaide Hospital, Medical Art and Design Women’s and Children’s Hospital, Burns Database 2007
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 Grade III

Women’s and Children’s Hospital, Burns Database 2007

Royal Adelaide Hospital, Medical Art and Design

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Rule of Nines to Estimate Body Surface Area

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Who, 2007 10
 % TBSA

The Nutrition and Dietetic Journey for the Burn Injured Patient within the Midland Burn Care Network: Guidelines for the Nutritional Management Of Adults and Paediatrics, 2011 11
 % TBSA

The Nutrition and Dietetic Journey for the Burn Injured Patient within the Midland Burn Care Network: Guidelines for the Nutritional Management Of Adults and Paediatrics, 2011 12
 Metabolic Changes in Burns

13
L. Kathleen, M, Sylvia, E.S, Janice, L. R, (2008). Krause’s Food and the Nutrition Care Process. 12th edition, International Edition. USA, Elsevier Saunders
 Metabolic Changes in Burns

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M. M. Chan and G. M. Chan / Nutrition 25 (2009) 261–269
 Nutrition Management for Burn
• Objective of Therapy

• Nutrition Therapy
Energy Requirements
Macronutrients Requirements
Micronutrients Requirements
Methods of Nutrition Support

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 Objective of Therapy

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L. Kathleen, M, Sylvia, E.S, Janice, L. R, (2008). Krause’s Food and the Nutrition Care Process. 12th edition, International Edition. USA, Elsevier Saunders
 Energy Requirements

Nutr Hosp. 2011;26(4):692-700 17

Nutr Hosp. 2011;26(4):692-700 18
 Energy Requirements
The Curreri formula may overestimate energy expenditure

the maximum caloric load that the body can handle is approximately 100% above resting
metabolic expenditure (2 x REE)

• 30-35 kcal/kg per day for burns < 40% BSA,

• 35-50 kcal/kg per day for burns ≥ 40% BSA
• Toronto equation is closest to the calorimetric determinations

Berger MM & Rene L.C, 2006

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L. Kathleen, M, Sylvia, E.S, Janice, L. R, (2008). Krause’s Food and the Nutrition Care Process. 12th edition, International Edition. USA, Elsevier Saunders
Energy Requirements

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 Energy Requirements
Hypothetically, was taken as reference for the use of formulas to a patient following conditions: 30 years old,
weighing 72 kg, height 170cm, 40% of TBSA, bedridden, with eight days of burning, body temperature of 37⁰C,
breathing spontaneously and with average intake of 2.000 calories per day

Nutr Hosp. 2011;26(4):692-700

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 Energy Requirements
 Over-nutrition  hyperglycemia, overload of the respiratory
system, steatosis and hyperosmolarity

 Under-nutrition  malnutrition and subsequent reduction of

immunocompetence, increased risk of infection, morbidity and
mortality

Nutr Hosp. 2011;26(4):692-700

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 Macronutrients Requirements
• Glucose infusion or delivery should be no more than 5-7 mg/kg/min (about 50% CHO
as energy)
• CHO for adult and children : 60 – 70% of TEE
• minimum amount of glucose (mg) which can be metabolised in 24 hours

:: (rate* x body weight (kg) x 60 minutes x 24 hours)::

*4-7 (always use lower value as a starting point for glucose administration)

Clinical Practice Guidelines Nutrition Burn Patient Management NSW Statewide Burn Injury Service, 2011
Manual of Dietetic Practice Book, 2007
Nutrition 25 (2009):261-269 23
 Macronutrients Requirements
• Protein for adult : 20 – 25% TEE or 1.3 – 3 g/IBW
• Protein for children : 2,5 – 4 g/kgBW
• BCAA

Nutrition 25 (2009) 261–269

Clinical Practice Guidelines Nutrition Burn Patient Management NSW Statewide Burn Injury Service, 2011 24
 Macronutrients Requirements

• Fat should constitute no more than 25-30% as energy, but in

fact 15-20% of non-protein energy as fat is optimal

• Fat for children : 20 – 25% TEE

• MCT

Nutrition 25 (2009) 261–269

Clinical Practice Guidelines Nutrition Burn Patient Management NSW Statewide Burn Injury Service, 2011 25
 Micronutrients Requirements
Micronutrient for Adult

S Afr J Clin Nutr 2009;22(1):09-15 26

 Micronutrients Requirements
Micronutrient for Childen > 3 Years

burns 3 3 (2 0 07 ) 1 4– 2 4
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 Fluid Management
Hartmann’s solution (Parkland Formula)

4 ml x % TBSA x Body weight (kg)

Children should have daily maintenance in addition to the fluid resuscitation

4ml/kg/Hr for the first 10kg

2ml/kg/Hr for between 10–20kg
1ml/kg/Hr for greater than 20kg

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 Fluid Management

• Initial 24 hours: Ringer’s lactated (RL) solution 4 ml/kg/% burn for adults
and 3 ml/kg/% burn for children.
• This formula recommends no colloid in the initial 24 hours.
• Next 24 hours: Colloids given as 20–60% of calculated plasma volume. No
crystalloids. Glucose in water is added in amounts required to maintain a
urinary output of 0.5–1 ml/hour in adults and 1 ml/hour in children.

Indian J Plast Surg. 2010 Sep; 43(Suppl): S29–S36. doi: 10.4103/0970-0358.70715 29

 Fluid Management

Modified Parkland formula

• Initial 24 hours: RL 4 ml/kg/% burn (adults)

• Next 24 hours: Begin colloid infusion of 5% albumin 0.3–1 ml/kg/% burn/16 per hour

Indian J Plast Surg. 2010 Sep; 43(Suppl): S29–S36. doi: 10.4103/0970-0358.70715 30

 Method of Nutrition Delivery
<15% in adult and <10% in children
• do not need resuscitation with intravenous fluid
• Oral diet and fluid should be encourage as soon as possible
>20% TBSA
• Resuscitation fluid by using RL
• Oral diet
• Nutrition support
NGT, Nasojejunum
Percutaneous Gastrostomy (PEG)

Manual of Dietetic Practice Book, 2007

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 Nutrition Care Process

• A,B,C,D,E data ND • Based on NM

• DI Etiology/ Sigh
• DB and symtomp • A,B,C,D,E data
• DC
NA PES
NI
Refer to Nutrition therapy

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 Nutrition Assessment

Anthropometri Biochemical Clinical Dietary

BW Leucosite %TBSA Reusitation fluid
High Albumin RR Intake
Electrolite Temperature Dietary history
CRP
Urinary Urea
Nitrogen (UUN)
Hb,
Blood glucose
etc

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 Nutrition Monitoring

burns 3 3 (2 0 07 ) 1 4– 2 4 34
 Nutrition Monitoring

burns 3 3 (2 0 07 ) 1 4– 2 4 35
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