NUTRITION OF THE

BURNED PATIENT
Prepared by

Rania Hassan Abdel Hafiez

Effects of Burn on the Body
 Extensive inflammatory response
 Rapid fluid shifts and accumulation.
 Hypermetabolic state
 Muscle protein catabolism
 Decrease cardiac output because of increased
capillary permeability and vasodilation.
 Heat loss
 Increased blood glucose levels
 Burn Shock
Nutrition Therapy Goals

 Promote wound healing

 Maintain lean body mass

 Restore fluid levels

Hypermetabolism
 Catecholamines, cortisol, and other
glucocorticoids are increased in burn
victims due to the stress state of the body
causing a hypermetabolic response.
 Epinephrine and norepinephrine increase

10-fold in people with burns greater that

30-40%.
 Hypermetabolic state lasts 9-12 months

after a burn.
Glucose Metabolism

 Accelerated gluconeogenesis, glucose

oxidation and plasma clearance of glucose
 Blood glucose levels increase due to insulin

resistance and breakdown of glycogen

stores
 Glucagon excretion by the liver increases

initially after the burn and slows down as

wound heals
Muscle Protein Catabolism
Protein catabolism increases in burn patients
leading to protein losses of 260 mg
protein/kg/hr.
Catabolic hormones counteract the effect of
insulin; as a result, blood sugar levels rise,
and protein synthesis and lipogenesis are
inhibited. Growth hormone is similarly
antagonized and less effective.
 In this environment, skeletal muscle is the

major obligatory fuel. (compare to starvation)

Role of Specific Nutrients:

 Kilocalories
 Supplied by carbohydrate, protein, fat
 Needed for optimal tissue repair
 Required for synthesis of new cells
 Sufficient calories is a priority so that
protein will be spared
Determining Kcal Needs

 Calculation of energy needs for

the burn patient remains
challenging
 % TBSA
 Degree of burn
 Other trauma involved
Determining Kcal Needs
 Predictive formulas
 At least 30 formulas have been proposed
 Harris-Benedict Equation: adds activity factor and stress
factor
 Ireton-Jones Equation: accounts for age, weight, gender,
presence of trauma or burn, and ventilatory status

 Kcalories/kg
 Used for less severe burns (<20% TBSA)
Determining Kcal Needs
 Indirect Calorimetry (Metabolic Cart)
 Considered to be the “gold standard”
 An indirect method of calculating energy
expenditure and respiratory quotient using
measurements of inspired and expired gas
 Most closely related to actual energy expenditure
 Accounts for variability in energy expenditure
from changes in metabolic state
Determining Kcal Needs
 Indirect Calorimetry, continued
 Requirements for a valid measurement:
Hemodynamically stable patient
A cooperative or sedated patient
Period of rest before measurement
FiO2 < 60%
Absence of chest tubes or other sources
of air leak
 Table 1: Nutrition Support for Burn
Injuries
Table 1 Use of the
Stressors Stress Burn factor Stress modified Harris-Benedict
Factors Factors equations to estimate
Activity factor resting energy
20% TBSA 1.2
Confined to bed 1.2 expenditure
20–25% TBSA 1.6 Men:
Out of bed 1.3 BEE=(66.47+13.75W+5.0
25–30%TBSA 1.7 H-6.76A)x(Activity
Injury factor Factor)x(Injury and/or
Minor operation 1.2 Burn Factor)
30–35% TBSA 1.8
Women:
Skeletal trauma 1.3 BEE=(655.1+19.56W+1.8
Major surgery 1.4 35–40% TBSA 1.9 5H-4.68A)x(Activity
Factor)
Sepsis 1.6 40% TBSA 2.0 x(Injury and/or Burn
Factor)

W=weight in kg;
H=height in cm;
Monitoring Nutritional
Status
 Body Weight
 Weight should be measured regularly
 Goal of weight maintenance is within 90%-110%
of pre-burn weight

 Prealbumin
 Short half-life of 2-3 days
 Reflects recent nutrition intake
 Depressed during acute phase response to burn
Monitoring Nutritional Status
 Nitrogen Balance
 Evaluates the adequacy of protein intake

 Needs a 24 hour urine collection and a 24 hr

UUN lab test

 Nitrogen balance = nitrogen intake - nitrogen

losses
Monitoring Nutritional Status
 Nitrogen Balance, continued
 Nitrogen intake = protein intake/6.25

 Nitrogen losses =
 Urinary nitrogen losses (24 hr UUN)
 Other losses from non-urea urinary nitrogen, fecal,
sweat, etc. (3-5 g)
 Burn wound nitrogen losses
 <10% open wound = 0.02 g/kg
 11% to 30% open wound = 0.05 g/kg
 >30% open wound = 0.12 g/kg
Monitoring Nutritional Status

 Indirect Calorimetry (Metabolic Cart)

 Periodic measurements aid in evaluating
adequacy of caloric intake

 Measures resting energy expenditure (REE)

A factor of 10% to 30% added for calorie needs during
PT and wound care
 Protein Requirements
 Amino acids are important for collagen synthesis for
wound healing
 Maintaining visceral protein is important for organ
function especially for immune systems
 Maintaining intercostal muscles and the

diaphragm is imperative for respiratory efficiency

 1.4-2.2 g/kg protein requirement for burns
 Urinary nitrogen losses increase with severity of the
burn injury
 Trauma patient may lose 20-25 g of lean body

nitrogen daily
Protein Requirement cont…
 Protein requirement estimate:
 Combine 24-hour urinary nitrogen loss, 2 to 4 g of
nitrogen for fecal loss and 4 to 5 g/d for anabolism.
 Convert each gram of nitrogen to 6.25 g of protein.
 Patients are likely to miss feedings if in surgery
frequently so should be given high protein
formulas between surgeries
 Be aware of uremia- increase free water
 Generally 20-25% of calories from protein
 Lipid requirements
 Lipid stores are critical for long-term fuel after
major thermal burns
 Fat oxidation is higher in hypermetabolic patients
than in normal patients
 Fat consumption should not exceed 30% of the diet
to avoid diarrhea
 Beneficial because
 Fat is a more concentrated form of energy
 Vegetable oils contain essential fatty acids and fat

soluble vitamins
 Help with infection
 Carbohydrate Requirements
 Carbohydrate metabolism is significantly affected in
burn patients
 Gluconeogenesis from Alanine and other AAs are
elevated
 Carbohydrates are good sources for protein sparing
especially for nitrogen retention
 High carbohydrates can contribute to hyperglycemia
in which case a diet can be altered to increase fat in
the diet
 Recommended 60% of the calories from CHO, not
surpassing 400g/d or1600 kcal/d
Vitamin C

 Needed for edema prevention

 Involved in collagen synthesis for wound healing
 Aid in immune functioning
Vitamin A

 Needed for immune function

 Epithelialization

 5000 IU of Vitamin A per 1000 cal

of enteral feeding is recommended

 Vitamin D and Calcium

 Burns cause an impairment in the metabolism of

Vitamin D
 Burn patients are more susceptible to fractures so
calcium and vitamin D should be administered
 Calcium- 1000 mg daily
 Vitamin D- 200-400 IU daily
 Maintain serum 25-hydroxy vitamin D level of

30-60 ng/Ml
Zinc and Copper

 Zinc and copper

deficiencies have been
seen in burn patients
most likely from tissue
breakdown and urinary
excretion.
 Supplementation is

recommended for
patients
Conditionally essential amino acids

Glutamine
Methods of Nutrient Delivery

 Oral Intake
 Burns <25% TBSA in older children
and adults and <15% TBSA in young
children and infants
 High-calorie, high-protein
supplements
 Modular calorie and protein
enhancement of oral foodstuffs
Methods of Nutrient Delivery

 Enteral Nutrition (EN)

 Most burn patients can tolerate a standard
formula
 Formula with high nitrogen content
 Transpyloric feedings are better tolerated
 EN is preferred to parenteral nutrition
(PN)
Methods of Nutrient Delivery
 Parenteral Nutrition (PN, TPN, PPN)
 Associated with complications
 Intestinaldysmotility
 Hepatic steatosis
 Septic morbidity
 Catheter-related infection
 ASPEN guidelines: limit use of PN to patients in
whom EN is contraindicated or unlikely to meet
nutritional needs in 4-5 days
Conclusions

 An aggressive nutrition approach for the

burn patient is indicated to:
 address hypermetabolism
 enhance nitrogen retention
 support wound healing
 improve survival
 Adequate nutrition

Successful wound healing

He has too much food to
eat

Thank you