Nutritional therapy among burn injured patients in the critical care setting: An international multicenter observational study on “best achievable” practices

Documented nutritional therapy in relation to nutritional guidelines post burn injury - a retrospective observational study

BACKGROUND & AIMS

Intensive nutritional therapy is an essential component of burn care. Regarding post-minor burn injuries, the literature is lacking. The aim of this study was to evaluate documented nutritional therapy in relation to international guidelines after both minor and major burn injuries. The secondary aim of this study was to evaluate the adequacy of energy and protein intake compared to individual nutritional goals post-burn injury.

METHODS

A retrospective observational single-centre study including patients admitted between 2017 and 2019 at a burn centre in Sweden was performed. The patients included in the study were ≥18 years old and in need of hospital care for ≥72 h post-burn injury. Information about patients' demographics, nutritional therapy, and clinical characteristics of burn injury was collected. The patients were divided according to total body surface area burnt (TBSA %) into minor burn injuries (TBSA <20%) and major burn injuries (TBSA ≥20%). Descriptive statistics were used to analyse data. Adherence to guidelines was established by comparing 24 nutritional therapy recommendations to documented treatment. If documented nutritional treatment were in accordance with guidelines, adherence was considered high (≥80%), moderate (60-79.9%) or low (<59.9%).

RESULTS

One hundred thirty-four patients were included, 90 patients with minor burn injuries and 44 patients with major burn injuries. Documented adherence to the nutritional guideline was overall low. After minor burn injury, 8% (2/24) of nutritional therapy recommendations had a high adherence (fat intake <35% of total energy intake and enteral nutrition as prioritized feeding route), 17% (4/24) a moderate adherence, and 75% (18/24) a low adherence. In patients treated after a major burn injury, there were two recommendations with documented high adherence (Vitamin C and Zinc); 25% (6/24) had moderate adherence, and 67% (16/24) had low adherence. In addition, quite a large amount of missing data was found. Adequacy of documented nutritional intake, compared to the individual documented goal, was 78% (±23%) for energy and 66% (±22%) for protein after minor burn injury. After major burn injury, the adequacy was 89% (±21%) for energy and 78% (±19%) for protein, respectively.

CONCLUSIONS

This study revealed low adherence to nutritional guidelines in patients treated for minor and major burn injuries. Compared to major burn injuries, lower documented adequacy for both energy and proteins was found in minor burn injuries. Given the disparity between guidelines and documented nutritional therapy, and the lack of specific guidelines for minor burn injuries, there could be a considerable risk of inadequate nutritional therapy post-burn injury.

The Efficacy of Glutamine Supplementation in Severe Adult Burn Patients: A Systematic Review With Trial Sequential Meta-Analysis

OBJECTIVES

Evidence supporting glutamine supplementation in severe adult burn patients has created a state of uncertainty due to the variability in the treatment effect reported across small and large randomized controlled trials (RCTs). We aimed to systematically review the effect of glutamine supplementation on mortality in severe adult burn patients.

DATA SOURCES

MEDLINE, Embase, CINAHL, and Cochrane Central were searched from inception to February 10, 2023.

STUDY SELECTION

RCTs evaluating the effect of enteral or IV glutamine supplementation alone in severe adult burn patients were included.

DATA EXTRACTION

Two reviewers independently extracted data on study characteristics, burn injury characteristics, description of the intervention between groups, adverse events, and clinical outcomes.

DATA SYNTHESIS

Random effects meta-analyses were performed to estimate the pooled risk ratio (RR). Trial sequential analyses (TSA) for mortality and infectious complications were performed. Ten RCTs (1,577 patients) were included. We observed no significant effect of glutamine supplementation on overall mortality (RR, 0.65, 95% CI, 0.33-1.28; p = 0.21), infectious complications (RR, 0.83; 95% CI, 0.63-1.09; p = 0.18), or other secondary outcomes. In subgroup analyses, we observed no significant effects based on administration route or burn severity. We did observe a significant subgroup effect between single and multicenter RCTs in which glutamine significantly reduced mortality and infectious complications in singe-center RCTs but not in multicenter RCTs. However, TSA showed that the pooled results of single-center RCTs were type 1 errors and further trials would be futile.

CONCLUSIONS

Glutamine supplementation, regardless of administration, does not appear to improve clinical outcomes in severely adult burned patients.

Adjusting body weight for edema in severely burned patients

Weight loss is difficult to quantify in critically ill burn patients, as the presence of edema can mask changes in dry body weight. We sought to estimate dry body weight using measured weights adjusted for reported extremity edema. We evaluated patients with at least 20% total body surface area (TBSA) burns admitted to our intensive care unit over a 3½-year period. Body weights were collected for this analysis from admission to the time of a recorded dry weight after wound healing. Extremity edema was collected at the time of each weight measurement and was categorized into three groups: (1) no edema, (2) 1 + pitting edema, (3) 2 + or 3 + pitting edema. Logistic regression yielded the following formula for estimating dry weight (in kg): 0.66 x measured body weight + 25 - (3 for 1 + pitting edema or 4 for 2 + or 3 + pitting edema of either upper extremity) - (4 for any pitting edema to either lower extremity) (p < 0.01, R2 = 0.81). These results may allow us to better estimate dry body weight changes in our edematous patients with severe burns. Nutrition goals can be adjusted earlier, when appropriate, based on these estimated dry body weight changes.

Nutrition after severe burn injury

PURPOSE OF REVIEW

Severe burn injury causes significant metabolic changes and demands that make nutritional support particularly important. Feeding the severe burn patient is a real challenge in regard to the specific needs and the clinical constraints. This review aims to challenge the existing recommendations in the light of the few recently published data on nutritional support in burn patients.

RECENT FINDINGS

Some key macro- and micro-nutrients have been recently studied in severe burn patients. Repletion, complementation or supplementation of omega-3 fatty acids, vitamin C, vitamin D, antioxidant micronutrients may be promising from a physiologic perspective, but evidence of benefits on hard outcomes is still weak due to the studies' design. On the contrary, the anticipated positive effects of glutamine on the time to discharge, mortality and bacteremias have been disproved in the largest randomized controlled trial investigating glutamine supplementation in burns. An individualized approach in term of nutrients quantity and quality may proof highly valuable and needs to be validated in adequate trials. The combination of nutrition and physical exercises is another studied strategy that could improve muscle outcomes.

SUMMARY

Due to the low number of clinical trials focused on severe burn injury, most often including limited number of patients, developing new evidence-based guidelines is challenging. More high-quality trials are needed to improve the existing recommendations in the very next future.

An overview of current research on nutritional support for burn patients: a bibliometric analysis from 1983 to 2022

OBJECTIVES

Burn patients are reportedly prone to complications, such as skeletal muscle wasting, anemia, and slow wound healing, during treatment, due to disease and metabolic depletion, which affect prognosis. Nutritional support is essential in treating burns and can significantly improve patient survival and reduce complications such as infection. This study aimed to perform a bibliometric analysis of the existing literature on nutritional support for burns and to explore possible future research trends.

METHODS

The literature related to nutritional support for burns from 1983 to 2022 was searched on Web of Science. The included literature was used for bibliometric analysis using VOSviewer and CiteSpace software.

RESULTS

There were 260 publications on nutritional support for burns. The United States contributes significantly to research in this area. The United States has the highest number of publications (n = 119) and citations (n = 4424). Nutrition support was the keyword with strongest burst intensity. A diet of ≥ 60% carbohydrates and 12% to 15% fat is suitable for burn patients, but the optimal ratios have not been fully determined.

CONCLUSIONS

An optimal nutritional support program is essential for treating burn patients. Individualized nutritional support programs are the trend in this field. At present, more rigorous multicenter prospective studies with large samples are needed to explore the optimal ratios for specific dietary programs, especially macronutrients, to achieve satisfactory nutritional support and improve patient prognosis.

Validation of the modified NUTrition Risk Score (mNUTRIC) in mechanically ventilated, severe burn patients: A prospective multinational cohort study

BACKGROUND

Whether nutrition therapy benefits all burn victims equally is unknown. To identify patients who will benefit the most from optimal nutrition, the modified Nutrition Risk in Critically Ill (mNUTRIC) Score has been validated in the Intensive Care Unit. However, the utility of mNUTRIC in severe burn victims is unknown. We hypothesized that a higher mNUTRIC (≥5) will be associated with worse clinical outcomes, but that greater nutritional adequacy will be associated with better clinical outcomes in patients with higher mNUTRIC score.

METHODS

This prospective study included data from mechanically ventilated, severe burn patients (n = 359) from 51 Burn Units worldwide included in a randomized trial. Our primary and secondary outcomes were hospital mortality and the time to discharge alive (TTDA) from hospital. We described the association between nutrition performance and clinical outcomes.

RESULTS

Compared to low mNUTRIC (n = 313), the high mNUTRIC group (n = 46) had higher mortality (61% vs. 19%, p = 0.001), and longer TTDA (>90 [87->90] vs. 64 [38-90] days, p = <0.0001). Only in the high mNUTRIC group, increased calorie intake (per 20% increase) was associated with lower mortality and a faster TTDA.

CONCLUSIONS

The mNUTRIC score identifies those with poor clinical outcomes and may identifies those mechanically ventilated, severe burn patients in whom optimal nutrition therapy may be more advantageous.

Endoscopic management of enteral tubes in adult patients - Part 1: Definitions and indications. European Society of Gastrointestinal Endoscopy (ESGE) Guideline

ESGE recommends considering the following indications for enteral tube insertion: (i) clinical conditions that make oral intake impossible (neurological conditions, obstructive causes); (ii) acute and/or chronic diseases that result in a catabolic state where oral intake becomes insufficient; and (iii) chronic small-bowel obstruction requiring a decompression gastrostomy.Strong recommendation, low quality evidence.ESGE recommends the use of temporary feeding tubes placed through a natural orifice (either nostril) in patients expected to require enteral nutrition (EN) for less than 4 weeks. If it is anticipated that EN will be required for more than 4 weeks, percutaneous access should be considered, depending on the clinical setting.Strong recommendation, low quality evidence.ESGE recommends the gastric route as the primary option in patients in need of EN support. Only in patients with altered/unfavorable gastric anatomy (e. g. after previous surgery), impaired gastric emptying, intolerance to gastric feeding, or with a high risk of aspiration, should the jejunal route be chosen.Strong recommendation, moderate quality evidence.ESGE suggests that recent gastrointestinal (GI) bleeding due to peptic ulcer disease with risk of rebleeding should be considered to be a relative contraindication to percutaneous enteral access procedures, as should hemodynamic or respiratory instability.Weak recommendation, low quality evidence.ESGE suggests that the presence of ascites and ventriculoperitoneal shunts should be considered to be additional risk factors for infection and, therefore, further preventive precautions must be taken in these cases.Weak recommendation, low quality evidence.ESGE recommends that percutaneous tube placement (percutaneous endoscopic gastrostomy [PEG], percutaneous endoscopic gastrostomy with jejunal extension [PEG-J], or direct percutaneous endoscopic jejunostomy [D-PEJ]) should be considered to be a procedure with high hemorrhagic risk, and that in order to reduce this risk, specific guidelines for antiplatelet or anticoagulant use should be followed strictly.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with advanced dementia.Strong recommendation, low quality evidence.ESGE recommends refraining from PEG placement in patients with a life expectancy shorter than 30 days.Strong recommendation, low quality evidence*.