Enteral nutrition: what the dietitian prescribes is not what the burn patient gets!

Optimizing Nutritional Needs of Burn Patients: An Evaluation of Nutritional Assessment Tools, Feeding Strategies, and Their Impact on Patient Outcomes

BACKGROUND

Optimal nutritional support is essential to the recovery and improved outcomes of burn patients. This review aims to explore existing literature to evaluate nutrition assessment tools, feeding formulations' caloric predictive ability, timing of initiation of feeding, optimal nutritional composition, and caloric intake in burn patients.

METHODS

Three databases were searched to glean studies investigating nutrition in acute severe adult burn patient populations in four areas: outcomes based on feeding type and timing, the caloric predictability of nutritional assessment tools, outcomes associated with the composition of feeding formulas, and considerations related to caloric intake. Outcomes of interest included the effects of nutritional assessments using feeding type, nutritional administration timing, formula composition, and caloric intake on mortality rate, length of stay, and infection.

RESULTS

A total of 19 studies were included. Nutritional assessment tools were determined to over- or underestimate resting energy expenditure (REE). Milner was the most accurate alternative to indirect calorimetry. Early enteral nutrition in burn patients within 24 hours of admission was preferred. 5 studies evaluated micronutrients and yielded variable results. Low-fat high-carbohydrate diets were the ideal macronutrient composition. Burn patients were shown to receive lower caloric intake than recommended.

CONCLUSIONS

Findings showed that while nutritional assessment tools tend to inaccurately estimate REE in burn patients, the ideal alternative to indirect calorimetry is the Milner equation. Several new equations may be worthy alternatives but require further validation. Enteral feeding should be initiated within the first 24 hours of burn injury whenever possible and should contain a high-carbohydrate/low-fat composition.

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.

Carry That Weight! The Challenge of Managing Weight Changes During Inpatient Admission for Patients With Burn Injuries ≥20% TBSA

The hypermetabolic state of patients with ≥20% total body surface area (TBSA) causes loss of muscle mass and compromised immune function with delayed wound healing. Weight loss is most severe in patients with ≥20% TBSA with initial weight gain due to fluid resuscitation. The American Burn Association (ABA) proposed quality measures for burn injury admissions, including weight loss from admission to discharge. We assessed how our outcomes adhere to these measures and if they correlate with previously described results. We retrospectively reviewed adult admissions with ≥20% TBSA burn injuries from 2016 to 2021. Four groups were established based on %TBSA: 20% to 29% (Group 1), 30% to 39% (Group 2), 40% to 59% (Group 3), and ≥60% (Group 4). We assessed weight changes from admission to discharge and performed multivariate analyses to account for age, sex, total surgeries, and length of stay. Data from 123 patients revealed 40 with 20% to 29% TBSA, 29 with 30% to 39% TBSA, 33 with 40% to 59% TBSA, 21 with ≥60% TBSA. A significant difference in weight loss was observed when comparing Groups 1 and 2 and Groups 3 and 4 (Group 1: −3.63%, Group 2: −2%, Group 3: −9.28%, Group 4: −13.85%; P-value ≤ .05). Groups 3 and 4 had significantly longer lengths of stay compared to Groups 1 and 2 (Group 1: 32.16, Group 2: 37.5, Group 3: 71.13, Group 4: 87.18; P-value ≤ .01). Most patients that experienced weight loss during their admission had &lt;15% weight loss. We found no significant difference in outcomes for patients receiving oxandrolone vs not. The mean weight change was −11% for patients with an overall weight loss and +5% for patients with an overall weight gain. The significant difference between the two groups was admission body mass index (BMI; loss: 30.4 kg/m2, gain: 26.0 kg/m2; P-value ≤ .05). Patients with ≥20% TBSA suffer weight changes, likely due to metabolic disturbances. Increased length of stay and higher %TBSA may be associated with greater weight loss. Patients experiencing weight gain had lower admission BMI suggesting that patients with higher BMI are more prone to weight loss. Our findings support that patients with %TBSA ≥40 are unique, requiring specialized nutritional protocols and metabolic analysis.

Safety and benefits of intraoperative enteral nutrition in critically ill pediatric burn patients: A systematic review and pooled analysis

Burn injuries significantly increase a patient's metabolic demand. Adequate nutrition is essential as an adjunct to recovery and reducing morbidity and mortality. In contrast to adults, this is especially important for pediatric patients who have limited reserves and are in a period of growth. Burn patients often require multiple anesthetic procedures that are accompanied by standard perioperative fasting periods that result in substantial nutritional interruptions. Continuous intraoperative feeding has been proposed as a solution, but there is no current consensus on its role and safety, particularly in the pediatric population. Thus, the goal of this study was to examine the safety and benefits of intraoperative nutrition in critically-ill pediatric burn injured patients. A systematic review of MEDLINE, PubMed, Scopus, and Web of Science was conducted using the following terms: feeding or enteral or nutrition or fasting and adolescent or youth or pediatric or child or teen and burn or thermal injury or fire. The primary outcome was incidence of aspiration. Secondary outcomes included patient nutritional status (caloric deficit and weight), wound healing, days spent in the intensive care unit, ventilator days, pneumonia, number of surgeries, length of hospital stay, and mortality. Pooled analyses of binary outcomes were computed. Four studies consisting of 496 patients, met inclusion criteria. All studies were level IV evidence, but had high methodological quality. The median burn total body surface area (TBSA) was 43.8% (IQR 33.4-58.8%), with a median of 30% of patients having an inhalational injury. Patients underwent a median of 4.2 surgeries (IQR 1.8-7.4). Intraoperative feeding was conducted through nasoduodenal tubes. There were no aspiration events. Pooled analysis demonstrated that there were no differences in rates of aspiration, pneumonia, or wound infection (p>0.05) between patients who were intraoperatively fed and those who were not. Those fed intraoperatively had significantly more surgeries, ventilator days, longer hospital stays, but lower mortality (p<0.05). There was large heterogeneity in nutritional assessment methods. Intraoperatively fed patients had an average gain of 144.4 kcal/kg,1.7 days of exclusive enteral nutrition (vs. loss of -119.1 kcal/kg and -1.4 days), and a cumulative positive caloric balance of +2673kcal ±2147 (vs. loss of -7899kcal ±3123) compared to those with interrupted feeding. Continuous intraoperative duodenal feeding during burn surgery appears to be safe in the pediatric burn population, with no reported episodes of aspiration. Uninterrupted feeding was also associated with weight maintenance and reduced caloric deficit. It may also have a survival benefit, as continuously fed patients needed more surgeries and intensive/hospital care, but had decreased mortality.

Risks in Management of Enteral Nutrition in Intensive Care Units: A Literature Review and Narrative Synthesis

Critically ill patients in the intensive care unit (ICU) have a high risk of developing malnutrition, and this is associated with poorer clinical outcomes. In clinical practice, nutrition, including enteral nutrition (EN), is often not prioritized. Resulting from this, risks and safety issues for patients and healthcare professionals can emerge. The aim of this literature review, inspired by the Rapid Review Guidebook by Dobbins, 2017, was to identify risks and safety issues for patient safety in the management of EN in critically ill patients in the ICU. Three databases were used to identify studies between 2009 and 2020. We assessed 3495 studies for eligibility and included 62 in our narrative synthesis. Several risks and problems were identified: No use of clinical assessment or screening nutrition assessment, inadequate tube management, missing energy target, missing a nutritionist, bad hygiene and handling, wrong time management and speed, nutritional interruptions, wrong body position, gastrointestinal complication and infections, missing or not using guidelines, understaffing, and lack of education. Raising awareness of these risks is a central aspect in patient safety in ICU. Clinical experts can use a checklist with 12 identified top risks and the recommendations drawn up to carry out their own risk analysis in clinical practice.

Why Delay? Early Enteral Nutrition in Pediatric Burn Patients Improves Outcomes

Children who sustain moderate to large surface area burns present in a hypermetabolic state with increased caloric and protein requirements. A policy was implemented at our institution in 2017 to initiate enteral nutrition (EN) in pediatric burn patients within 4 hours of admission. The authors hypothesize that early EN (initiated within 4 hours of admission) is more beneficial than late EN (initiated ≥ 4 hours from admission) for pediatric burn patients and is associated with decreased rates of pneumonia, increased calorie and protein intake, fewer feeding complications, a shorter Intensive Care Unit (ICU) length of stay (LOS), and a reduced hospital LOS. Children who sustained a total body surface area (TBSA) burn injury ≥ 10% between 2011 and 2018 were identified in a prospectively maintained burn registry at Children's Hospital Colorado. Patients were stratified into two groups for comparison: early EN and late EN. The authors identified 132 pediatric burn patients who met inclusion criteria, and most (60%) were male. Approximately half (48%) of the study patients were in the early EN group. The early EN group had lower rates of underfeeding during the first week (P = .014) and shorter ICU LOS (P = .025). Achieving and sustaining adequate nutrition in pediatric burn patients with moderate to large surface area burn injuries are critical to recovery. Early EN in pediatric burn patients is associated with decreased underfeeding and reduced ICU LOS. The authors recommend protocols to institute feeding for patients with burns ≥ 10% TBSA within 4 hours of admission at all pediatric burn centers.

Evaluating the Safety and Efficacy of Intraoperative Enteral Nutrition in Critically Ill Burn Patients: A Systematic Review and Meta-analysis

Major burn injuries incite a hypermetabolic response, and the initiation of early enteral nutrition is the standard of care in patients with large burns and contributes to improved outcomes. Perioperative fasting is a common cause of caloric deficits in burn patients and can be obviated with intraoperative enteral nutrition. However, the risks and benefits of this practice are unknown, and there is a concern for aspiration. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of intraoperative enteral nutrition. We performed a systematic literature search using PubMed, Scopus, and OvidSP MEDLINE databases. We identified studies that evaluated the effects of intraoperative enteral nutrition in adult burn patients compared to those undergoing routine perioperative fasting. We performed a meta-analysis on the incidence of mortality, pneumonia, wound infections, and aspiration in burn patients receiving intraoperative enteral nutrition. We identified seven articles for qualitative review and four for quantitative review (N = 83 patients). There were no statistically significant increases in the risk of mortality (odds ratio [OR] = 1.28, 95% confidence interval [CI]: 0.49, 3.31), wound infections (OR = 0.71, 95% CI: 0.16, 3.24), pneumonia (OR = 2.1, 95% CI: 0.7, 6.1), and aspiration (OR = 1.14, 95% CI: 0.07, 18.75) in patients receiving intraoperative enteral nutrition. Within individual studies, intraoperative enteral nutrition patients received significantly more calories than standard fasting patients. Intraoperative enteral nutrition may increase nutritional intake in burn patients without an increase in complications; however, this is based on limited studies. Randomized controlled trials are needed before recommendations on intraoperative enteral nutrition practice can be made.

Interrupted Nutrition Support in Patients With Burn Injuries: A Single-Centre Observational Study

Background

Enteral nutrition (EN) is essential to meet the increased metabolic requirements of burn-injured patients. However, feeds are often suspended for care. This study examines the interruptions in EN (IEN).

Objective

To determine the frequency and duration of IEN and whether these interruptions are predictable or unpredictable.

Design

This retrospective chart review of 27 adult burn patients examined age, sex, body mass index, percentage of total body surface area, length of hospital stay, predicted energy requirements from equations and indirect calorimetry, EN start time, time EN reached goal rate, and interruptions to EN.

Results

Predictable interruptions accounted for 74.5% (frequency) and 81.6% (duration) of total interruptions. The most frequent and time-consuming interruptions were perioperative period, extubation, and tests/procedures (predictable) versus high gastric residual volume, emesis/nausea, and feeding tube displacement (unpredictable).

Conclusions

Most IEN were due to predictable events. Based on these findings, compensating for predictable interruptions to meet nutritional requirements in burn patients is recommended.

A prospective observation on nutrition support in adult patients with severe burns

Nutrition therapy is considered an important treatment of burn patients. The aim of the study was to delineate the nutritional support in severe burn patients and to investigate association between nutritional practice and clinical outcomes. Severe burn patients were enrolled (n 100). In 90 % of the cases, the burn injury covered above 70 % of the total body surface area. Mean interval from injury to nutrition start was 2·4 (sd 1·1) d. Sixty-seven patients were initiated with enteral nutrition (EN) with a median time of 1 d from injury to first feed. Twenty-two patients began with parenteral nutrition (PN). During the study, thirty-two patients developed EN intolerance. Patients received an average of about 70 % of prescribed energy and protein. Patients with EN providing &lt;30 % energy had significantly higher 28- d and in-hospital mortality than patients with EN providing more than 30 % of energy. Mortality at 28 d was 11 % and in-hospital mortality was 45 %. Multiple regression analysis demonstrated that EN providing &lt;30 % energy and septic shock were independent risk factors for 28- d prognosis. EN could be initiated early in severe burn patients. Majority patients needed PN supplementation for energy requirement and EN feeding intolerance. Post-pyloric feeding is more efficient than gastric feeding in EN tolerance and energy supplement. It is difficult for severe burn patients to obtain enough feeding, especially in the early stage of the disease. More than 2 weeks of underfeeding is harmful to recovery.

Weight changes and patterns of weight measurements in hospitalized burn patients: a contemporary analysis

Background

Severe burn is associated with significant changes in body weight due to resuscitation volumes, fluid shifts, a hypermetabolic state, prolonged bed rest, and caloric intake. Our goal was to quantify and describe trends in weight change in patients with burns of all severities under modern treatment conditions and to identify the time points at which these changes occur.

Methods

An institutional review board-approved chart review was conducted of acute burn patients treated at an American Burn Association-verified regional burn center from February 2016 to November 2016. Patients were then divided into three groups based on percent of total burn surface area (%TBSA) burn: 1–19%, 20–39%, and ≥ 40%. Weight was expressed as percent change of weight from baseline. Regression analysis was conducted on percent weight changes for each TBSA group.

Results

We identified 197 burn patients with a length of stay (LOS) of ≥ 7 days. Of the study cohort, 149 had TBSA burn of 1–19%, 27 had TBSA burn of 20–39%, and 21 had TBSA burn of ≥ 40%. All groups had a majority of White male, non-Hispanic patients with mean ages between 40 and 42 years. Burn patients with > 20% TBSA burn had a median increase in weight above baseline of approximately 5 to 8% likely due to resuscitation fluids within the first week of hospitalization. Weight loss below baseline often did not exceed 10% and was more pronounced as LOS increased, mostly in patients with > 20% TBSA burn. Whereas patients with 1–19% TBSA burn on average returned to baseline weight at last measurement, patients with 20–39% TBSA and ≥ 40% TBSA burn continued a decline in weight at 4 weeks (r² = 0.57 and 0.55, respectively) on the same trajectory.

Conclusions

Burn patients with > 20% TBSA burn had an increase in weight above baseline of up to 8%, likely due to resuscitation fluids within the first week of hospitalization. Weight loss below baseline often did not exceed 10% and was more pronounced as LOS increased, mostly in patients with > 20% TBSA burn. Therefore, our patients on average, lost body weight to a lesser extent than the maximum mean loss of 22% of pre-burn weight reported prior to modern treatment conditions.

How long are burn patients really NPO in the perioperative period and can we effectively correct the caloric deficit using an enteral feeding "Catch-up" protocol?

OBJECTIVE

"NPO at midnight" is a standard preoperative practice intended to reduce aspiration risk but can result in prolonged feeding interruptions in critically ill burn patients. Postoperative hyperalimentation in the form of a "catch-up" tube feeding protocol is routine. A retrospective review of our perioperative fasting practices and "catch-up" enteral feeding protocols was performed.

METHODS

Patients admitted to the Burn ICU from July 1st, 2015 to August 31st, 2016 were reviewed. Patients who had a protected airway in place, prescribed enteral nutrition, and underwent surgery were included. The time from NPO to surgical start (NPO-SS), NPO to feeding restart (NPO-FR), and calories received/prescribed were quantified. The efficacy of a postoperative catch-up feeding protocol was analyzed.

RESULTS

There were 41 patients that fit inclusion criteria with some undergoing multiple surgeries, yielding 109 surgeries/discrete perioperative events. The average total body surface area burn (38.1±23.6%), age (38.8±20.1years), ICU days (45.0±37.3 days), and ventilator days (35.1±33.8 days) were calculated. Average fasting durations of NPO-SS and NPO-FR were 9.3±3.1 and 14.2±4.1h, respectively. The average caloric deficit to prescribed calories ratio during the NPO-SS and NPO-FR periods were 1154±629/3534±851kcal and 1765±928/3534±851kcal, respectively. A post-operative catch-up protocol completely compensated for perioperative caloric deficits 68.8% (22/32) of the time.

CONCLUSIONS

In critically ill burn patients, a preoperative fast resulted in an average loss of greater than 50% of prescribed calories on the day of surgery. Clinicians should re-evaluate the standard practice of making preoperative patients "NPO at midnight". An effective catch-up protocol can adequately reduce caloric deficits.

Nutrition in burn injury: any recent changes?

PURPOSE OF REVIEW

After major progress in the 1980s of burn resuscitation resulting, the last years' research has focused on modulation of metabolic response and optimization of substrate utilization. The persisting variability of clinical practice is confirmed and results in difficult comparisons between burn centers.

RECENT FINDINGS

Recent research explores intracellular mechanisms of the massive metabolic turmoil observed after burns: very early alterations at the mitochondrial level largely explain the hypermetabolic response, with a diminished coupling of oxygen consumption and ATP production. The metabolic alterations (elevated protein and glucose turnover) have been shown to be long lasting. Modulating this response by pharmacological tools (insulin, propranolol, and oxandrolone) results in significant clinical benefits. A moderate glucose control proves to be safe in adult burns; data in children remain uncertain as the risk of hypoglycemia seems to be higher. The enteral feeding route is confirmed as an optimal route: some difficulties are now clearly identified, such as the risk of not delivering sufficient energy by this route.

SUMMARY

Major burn patients differ from other critically ill patients by the magnitude and duration of their inflammatory and metabolic responses, their energy and substrate requirements. Pieces of the metabolic puzzle finally seem to fit together.

Update on metabolism and nutrition therapy in critically ill burn patients

Major burn injury triggers severe oxidative stress, a systemic inflammatory response, and a persistent hypermetabolic and hypercatabolic state with secondary sarcopenia, multiorgan dysfunction, sepsis and an increased mortality risk. Calorie deficit, negative protein balance and antioxidant micronutrient deficiency after thermal injury have been associated to poor clinical outcomes. In this context, personalized nutrition therapy with early enteral feeding from the start of resuscitation are indicated. Over the last four decades, different nutritional and pharmacological interventions aimed at modulating the immune and metabolic responses have been evaluated. These strategies have been shown to be able to minimize acute malnutrition, as well as modulate the immunoinflammatory response, and improve relevant clinical outcomes in this patient population. The purpose of this updating review is to summarize the most current evidence on metabolic response and nutrition therapy in critically ill burn patients.