Maine Medical Center, Medical Education, Maine Medical Center Research Institute
Adult, Burns, Physical Phenomena, Humans
Background: It is estimated that more than 2 million people suffer burn injuries in the United States annually, resulting in approximately 3400 deaths. Burns cause pathological alterations in nearly every system of the body and changes in both metabolism and immunity in burned patients contribute to adverse outcomes. Hypermetabolism leads to severe catabolism and loss of lean body mass in the severely burned patient making nutrition intervention critical. Literature indicates that enteral nutrition alone does not prevent hypermetabolism after a major burn injury, but nutrition intervention can improve outcomes. Although nutrition supplementation is widely regarded as beneficial, controversy regarding a patient’s nutrition needs throughout the phases of burn recovery continue to challenge health care providers. Registered Dietitians (RDs) have a critical role in the interdisciplinary team to provide evidence based recommendations for nutrition intervention.
Purpose: Develop evidence based guidelines for Maine Medical Center (MMC) RDs to estimate energy and protein needs for adult burn patients with >20% total body surface area (TBSA) injury. Methods/Approach: As part of the MMC Clinical Scholars Program, initiated a literature search for peer reviewed journal articles and care guidelines about nutrition care for adult burn patients. A secondary literature search was conducted with assistance from MMC library staff which found limited articles and limited access to burn related journals. The most recent evidence based practice guidelines were collected and reviewed including the American Society for Enteral and Parenteral Nutrition (ASPEN) Critical Care Guidelines 2016, European Society for Enteral and Parenteral Nutrition (ESPEN) Guidelines, and American Burn Association Care Guidelines. At the time of the initial literature review, MMC did not have access to the latter. A critical appraisal of the literature available was conducted to draw current conclusions focusing on assessment of energy and protein needs.
Results/Conclusions: MMC acquired access to the Journal of Burn Care and Research as a result of this study. First the definition of ‘major burns’ needing possible nutrition intervention was identified as those >20% TBSA. Indirect calorimetry (IC) is the well-established ‘gold standard’ for determining energy needs in patients with major burns. IC should be completed as soon as possible, done in the ‘fed state,’ and rechecked weekly to biweekly. Research varies about the need to then multiply the value obtained from IC by an activity factor. The studies that support using an activity factor agree on 1.2-1.4 or 30% as the activity factor, however further research is needed before making recommendations about this component. Significant variability exists amongst research as to which predictive equations are most accurate for assessing energy needs when indirect calorimetry cannot be performed. Predictive equations have been shown to both over and underestimate needs. Several studies support using the Toronto or Milner equations and several studies caution against using the Harris Benedict or KKD formulas. Estimated protein need recommendations are well established at 1.5-2.0 g/kg. Research also suggested that no further benefit is seen in providing > 2.2 g/kg of protein. Further investigation into using ideal versus actual body weight in this calculation is needed
Lazarz, Ashley and Waller, Samantha Buttarazzi, "Evidence based estimation of energy and protein needs in adults with major burn injuries" (2020). Costas T. Lambrew Research Retreat 2020. 54.