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Zagales R, Watts E, Awan MU, Hernandez N, Haddadi M, Smith HG, Elkbuli A. Optimizing Nutritional Needs of Burn Patients: An Evaluation of Nutritional Assessment Tools, Feeding Strategies, and Their Impact on Patient Outcomes. Am Surg 2024:31348241259042. [PMID: 38830580 DOI: 10.1177/00031348241259042] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024]
Abstract
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.
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Affiliation(s)
- Ruth Zagales
- Indiana University School of Medicine, Bloomington, IN, USA
| | - Emelia Watts
- Kiran Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Muhammad Usman Awan
- Kiran Patel College of Allopathic Medicine, NOVA Southeastern University, Fort Lauderdale, FL, USA
| | - Nickolas Hernandez
- William Carey University College of Osteopathic Medicine, Hattiesburg, MS, USA
| | - Minna Haddadi
- American University of Antigua College of Medicine, Coolidge, Antigua and Barbuda
| | - Howard G Smith
- Director of Burn Surgery, Warden Burn Center, Orlando Health, Orlando, FL, USA
| | - Adel Elkbuli
- Department of Surgery, Division of Trauma and Surgical Critical Care, Orlando Regional Medical Center, Orlando, FL, USA
- Department of Surgical Education, Orlando Regional Medical Center, Orlando, FL, USA
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Wang Y, Jiang J, Liu M, Liu H, Shen T, Han C, Wang X. Estimates of resting energy expenditure using predictive equations in adults with severe burns: A systematic review and meta-analysis. JPEN J Parenter Enteral Nutr 2024; 48:267-274. [PMID: 38409876 DOI: 10.1002/jpen.2617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2023] [Revised: 02/05/2024] [Accepted: 02/05/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND Many equations to estimate the resting energy expenditure (REE) of patients with burns are currently available, but which of them provides the best guide to optimize nutrition support is controversial. This review examined the bias and precision of commonly used equations in patients with severe burns. METHODS A systematic search of the PubMed, Web of Science, Embase, and Cochrane Library databases was undertaken on June 1, 2023, to identify studies comparing predicted REE (using equations) with measured REE (by indirect calorimetry [IC]) in adults with severe burns. Meta-analyses of bias and calculations of precisions were performed in each predictive equation, respectively. RESULTS Nine eligible studies and 12 eligible equations were included. Among the equations, the Toronto equation had the lowest bias (26.1 kcal/day; 95% CI, -417.0 to 469.2), followed by the Harris-Benedict equation × 1.5 (1.5HB) and the Milner equation. The Ireton-Jones equation (303.4 kcal/day; 95% CI, 224.5-382.3) acceptably overestimated the REE. The accuracy of all of the equations was <50%. The Ireton-Jones equation had the relatively highest precision (41.2%), followed by the 1.5HB equation (37.0%) and the Toronto equation (34.7%). CONCLUSION For adult patients with severe burns, all of the commonly used equations for the prediction of REE are inaccurate. It is recommended to use IC for accurate REE measurements and to use the Toronto equation, 1.5HB equation, or Ireton-Jones equation as a reference when IC is not available. Further studies are needed to propose more accurate REE predictive models.
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Affiliation(s)
- Yiran Wang
- Department of Burns & Wound Care Center, The Second Affiliated Hospital of Zhejiang University College of Medicine, Hangzhou, China
- The Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
| | - Jing Jiang
- Department of Burns & Wound Care Center, The Second Affiliated Hospital of Zhejiang University College of Medicine, Hangzhou, China
- The Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
| | - Meixuan Liu
- Department of Burns & Wound Care Center, The Second Affiliated Hospital of Zhejiang University College of Medicine, Hangzhou, China
- The Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
| | - Huan Liu
- Department of Burns & Wound Care Center, The Second Affiliated Hospital of Zhejiang University College of Medicine, Hangzhou, China
- The Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
| | - Tao Shen
- Department of Burns & Wound Care Center, The Second Affiliated Hospital of Zhejiang University College of Medicine, Hangzhou, China
| | - Chunmao Han
- Department of Burns & Wound Care Center, The Second Affiliated Hospital of Zhejiang University College of Medicine, Hangzhou, China
- The Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
| | - Xingang Wang
- Department of Burns & Wound Care Center, The Second Affiliated Hospital of Zhejiang University College of Medicine, Hangzhou, China
- The Key Laboratory of the Diagnosis and Treatment of Severe Trauma and Burn of Zhejiang Province, Hangzhou, China
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Revised Harris-Benedict Equation: New Human Resting Metabolic Rate Equation. Metabolites 2023; 13:metabo13020189. [PMID: 36837808 PMCID: PMC9967803 DOI: 10.3390/metabo13020189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 01/11/2023] [Accepted: 01/23/2023] [Indexed: 01/31/2023] Open
Abstract
This paper contains a revision of the Harris-Benedict equations through the development and validation of new equations for the estimation of resting metabolic rate (RMR) in normal, overweight, and obese adult subjects, taking into account the same anthropometric parameters. A total of 722 adult Caucasian subjects were enrolled in this analysis. After taking a detailed medical history, the study enrolled non-hospitalized subjects with medically and nutritionally controlled diseases such as diabetes mellitus, cardiovascular disease, and thyroid disease, excluding subjects with active infections and pregnant or lactating women. Measurement of somatometric characteristics and indirect calorimetry were performed. The values obtained from RMR measurement were compared with the values of the new equations and the Harris-Benedict, Mifflin-St Jeor, FAO/WHO/UNU, and Owen equations. New predictive RMR equations were developed using age, body weight, height, and sex parameters. RMR males: (9.65 × weight in kg) + (573 × height in m) - (5.08 × age in years) + 260; RMR females: (7.38 × weight in kg) + (607 × height in m) - (2.31 × age in years) + 43; RMR males: (4.38 × weight in pounds) + (14.55 × height in inches) - (5.08 × age in years) + 260; RMR females: (3.35 × weight in pounds) + (15.42 × height in inches) - (2.31 × age in years) + 43. The accuracy of the new equations was tested in the test group in both groups, in accordance with the resting metabolic rate measurements. The new equations showed more accurate results than the other equations, with the equation for men (R-squared: 0.95) showing better prediction than the equation for women (R-squared: 0.86). The new equations showed good accuracy at both group and individual levels, and better reliability compared to other equations using the same anthropometric variables as predictors of RMR. The new equations were created under modern obesogenic conditions, and do not exclude individuals with regulated (dietary or pharmacological) Westernized diseases (e.g., cardiovascular disease, diabetes, and thyroid disease).
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Osborne T, Wall B, Edgar DW, Fairchild T, Wood F. Current understanding of the chronic stress response to burn injury from human studies. BURNS & TRAUMA 2023; 11:tkad007. [PMID: 36926636 PMCID: PMC10013650 DOI: 10.1093/burnst/tkad007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 12/26/2022] [Accepted: 01/17/2023] [Indexed: 03/15/2023]
Abstract
There is a marked inflammatory and hypermetabolic response following a burn injury. The interlinked responses are more pronounced than for other forms of trauma and can persist for ≥3 years post-injury in burned patients. After a burn, patients have an increased risk of diseases of ageing including cancer, diabetes and cardiovascular disease, highlighting the need for effective long-term strategies to ameliorate the stress response post-burn. Current therapeutic strategies for post-burn recovery include removal of damaged tissue with surgical excision and wound repair, nutritional supplementation and rehabilitative exercise. These strategies aim to minimize the hypermetabolic and inflammatory responses, as well as reducing the loss of lean body mass. This review briefly summarises the inflammatory and hypermetabolic responses and provides an update on the current therapeutic strategies for burned patients. The review examines the persistent nutritional challenge of ensuring sufficient energy intake of each macronutrient to fuel the hypermetabolic and counteract the catabolic response of burn injury, whilst reducing periods of hyperglycaemia and hypertriglyceridemia. Patients require individualized treatment options tailored to unique systemic responses following a burn, facilitated by a precision medicine approach to improve clinical and physiological outcomes in burned patients. Thus, this review discusses the utility of metabolic flexibility assessment to aid clinical decision making and prescription relating to nutritional supplementation and rehabilitative exercise in the burned patient.
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Affiliation(s)
- Tyler Osborne
- Discipline of Exercise Science, Murdoch University, Murdoch 6150, Western Australia.,Centre for Healthy Ageing, Health Futures Institute, Murdoch University, Murdoch 6150, Western Australia
| | - Bradley Wall
- Discipline of Exercise Science, Murdoch University, Murdoch 6150, Western Australia.,Centre for Healthy Ageing, Health Futures Institute, Murdoch University, Murdoch 6150, Western Australia
| | - Dale W Edgar
- State Adult Burns Unit, Government of Western Australia South Metropolitan Health Service, Fiona Stanley Hospital, Murdoch 6150, Western Australia.,Fiona Wood Foundation, Fiona Stanley Hospital, Murdoch 6150, Western Australia.,Burn Injury Research Node, Institute for Health Research, The University of Notre Dame Australia, Murdoch 6160, Western Australia.,Burn Injury Research Unit, University of Western Australia, Murdoch 6009, Western Australia
| | - Timothy Fairchild
- Discipline of Exercise Science, Murdoch University, Murdoch 6150, Western Australia.,The Centre for Molecular Medicine and Innovative Therapeutics, Health Futures Institute, Murdoch University, Murdoch 6150, Western Australia
| | - Fiona Wood
- State Adult Burns Unit, Government of Western Australia South Metropolitan Health Service, Fiona Stanley Hospital, Murdoch 6150, Western Australia.,Fiona Wood Foundation, Fiona Stanley Hospital, Murdoch 6150, Western Australia.,Burn Injury Research Unit, University of Western Australia, Murdoch 6009, Western Australia
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Sasaki J, Matsushima A, Ikeda H, Inoue Y, Katahira J, Kishibe M, Kimura C, Sato Y, Takuma K, Tanaka K, Hayashi M, Matsumura H, Yasuda H, Yoshimura Y, Aoki H, Ishizaki Y, Isono N, Ueda T, Umezawa K, Osuka A, Ogura T, Kaita Y, Kawai K, Kawamoto K, Kimura M, Kubo T, Kurihara T, Kurokawa M, Kobayashi S, Saitoh D, Shichinohe R, Shibusawa T, Suzuki Y, Soejima K, Hashimoto I, Fujiwara O, Matsuura H, Miida K, Miyazaki M, Murao N, Morikawa W, Yamada S. Japanese Society for Burn Injuries (JSBI) Clinical Practice Guidelines for Management of Burn Care (3rd Edition). Acute Med Surg 2022; 9:e739. [PMID: 35493773 PMCID: PMC9045063 DOI: 10.1002/ams2.739] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2021] [Revised: 01/29/2022] [Accepted: 02/03/2022] [Indexed: 01/28/2023] Open
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Rattanachaiwong S, Singer P. Indirect calorimetry as point of care testing. Clin Nutr 2019; 38:2531-2544. [PMID: 30670292 DOI: 10.1016/j.clnu.2018.12.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2018] [Revised: 12/10/2018] [Accepted: 12/29/2018] [Indexed: 02/06/2023]
Abstract
Determining energy requirement is a fundamental of nutrition support. Indirect calorimetry (IC) has been long recognized as the gold standard for assessing basal or resting energy expenditure (REE). The measurement of REE is recommended particularly in the situation where adjustment of energy provision is critical. The result of the IC measurement can lead to changes in treatment and since the change can be carried out immediately at the bedside, this may be considered as point-of-care testing. Beyond the nutritional aspects, studies of energy expenditure with IC have brought out more understanding of the metabolic changes during the natural course of diseases or conditions as well as those related to the intervention. The literature in various disease states has shown that changes in energy expenditure may reveal hidden metabolic information that might be translated into clinical information and have the potential of being both prognostic indicators and/or treatment targets.
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Affiliation(s)
- Sornwichate Rattanachaiwong
- Division of Clinical Nutrition, Department of Medicine, Faculty of Medicine, Khon Kaen University, Thailand.
| | - Pierre Singer
- Department of General Intensive Care, Rabin Medical Center, Petah Tikva and Sackler School of Medicine, Tel Aviv University, Israel
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Reliability of resting energy expenditure in major burns: Comparison between measured and predictive equations. Clin Nutr 2018; 38:2763-2769. [PMID: 30579670 DOI: 10.1016/j.clnu.2018.12.003] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2018] [Revised: 09/26/2018] [Accepted: 12/04/2018] [Indexed: 11/20/2022]
Abstract
BACKGROUND & AIMS Poor outcomes can result from inadequate energy intake. We aimed to investigate the reliability of resting energy expenditure (REE) measured by indirect calorimetry (IC) with REE calculated using predictive equations for nutritional support in patients with major burns. METHODS REE was measured using IC and compared with predictive equations in 215 adult severe burns patients from Jan 2011 to Jun 2015. Agreement between IC and predictive equations was assessed using Bland-Altman methods. RESULTS All predictive equations, including newly developed Hangang equation, were compared with REE measured using IC. The mean measured REE was 1712 kcal/d. Bland-Altman analysis showed that 1.2 times HBE, Thumb 25, and Ireton-Jones equations had higher accuracy and reliability. The concordance correlation coefficient was higher (0.49) in the Ireton-Jones equation, and root mean square error (RMSE) was lowest (471.5) in the Thumb 25 equation. The proportion of patients with predicted REE within ±10% of measured REE was highest with Thumb 25 (52.5%). In the validation set, the Hangang equation showed the highest Lin's concordance correlation coefficient (0.67) and the lowest RMSE (311.4). Other equations for burns patients had higher mean bias and overestimated REE when compared with IC results. CONCLUSIONS This study suggests that Thumb 25 can be used as an alternative method for estimating energy requirements of patients with major burns when IC is not available or applicable. However, for these patients with significant variation in metabolism over time, an alternative equation is the new Hangang equation.
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Elder K, Hill DM, Hickerson WL. Characterization of variables for potential impact on vancomycin pharmacokinetics in thermal or inhalation injury. Burns 2017; 44:658-664. [PMID: 29097070 DOI: 10.1016/j.burns.2017.10.004] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 10/06/2017] [Accepted: 10/08/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To characterize the pharmacokinetics of vancomycin dosing in thermal or inhalation injury as they relate to percent total body surface area burn (TBSA) and days since injury (DSI). METHODS This retrospective 3-year study included patients with thermal or inhalation injury receiving vancomycin. Patient demographics and course data were collected using the institution's electronic medical record. RESULTS Six hundred and fifty-four patients were included in the study; 124 remained after exclusion. Clearance (CL) was augmented in patients closer to their date of injury. CL and total daily dose requirements significantly increased with larger percent TBSA injured that was independent of volume of distribution (Vd). Larger percent TBSA also predicted increased occurrence of renal injury prior to vancomycin initiation. A modified sample set was also analyzed to control for renal dysfunction. Creatinine clearance (CrCl) estimated via the Cockcroft-Gault equation significantly impacted CL and total daily dose. To obtain a goal trough of 15-20mg/L, the average patient in the modified sample with ≥10% TBSA required 64.7mg/kg/day (or 16.2mg/kg every 6hours). CONCLUSIONS DSI, percent TBSA, and CrCl can be used to predict faster vancomycin CL and need for higher total daily doses. Augmented pharmacokinetics can occur as early as two days after injury and decrease with time. Acceptable target trough attainment is still lacking and this data should assist in performance improvements for initial vancomycin dosing.
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Affiliation(s)
- Katie Elder
- Department of Pharmacy, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA
| | - David M Hill
- Director of Burn Research, Firefighters Burn Center; Clinical Pharmacist, Department of Pharmacy, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Assistant Professor, Department of Clinical Pharmacy, College of Pharmacy, University of Tennessee Health Science Center, 881 Madison Ave, Memphis, TN 38163, USA.
| | - William L Hickerson
- Medical Director, Department of Plastic Surgery, Firefighters Regional Burn Center, Regional One Health, 877 Jefferson Avenue, Memphis, TN 38103, USA; Professor, Department of Plastic Surgery, College of Medicine, University of Tennessee Health Science Center, Memphis, TN 38103, USA.
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