History of Metabolic Treatments in Burn Care

6/30/2008
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Author(s):

Ahmed M. Al-Mousawi, MD; Marc G. Jeschke, MD, PhD; David N. Herndon, MD

Thermally Neutral Ambient Temperature

Evaporation at the burn eschar causes heat loss, which contributes to the energy requirements of the already hypermetabolic burn patient. Water loss can be as much as 4 L per m² TBSA burn per day.^46,47 Similar to cold acclimatization mediated by the hypothalamus, core and skin temperatures are reset to 2˚C above normal in patients with severe burns. In 1975, Wilmore et al⁶ showed hypermetabolism following large burns could be significantly reduced by warming to a thermally neutral ambient temperature of 33˚C at which point the heat required for evaporation derives from the environment rather than the patient.

Nutritional Support of Hypermetabolism

Nutritional support is vitally important to improve outcomes following major burn injury and to meet the demands of the metabolic response. In the early 1970s before routine nutritional support via enteral or parenteral feeding, patients with severe burns could be expected to lose 15% of their lean body mass within a few weeks of injury due to severe catabolism, a major factor contributing to the prevailing mortality rates.^48,49

Severe burn injury results in a catabolic state, increasing proteolysis by up to 50%, and results in profound loss of muscle mass.⁵⁰ The hypermetabolic response that follows severe burn trauma causes an elevation in energy expenditure of up to 100% above normal. Shaffer and Coleman⁵¹ had advocated high caloric feeding for burn patients as early as 1909. In 1971, Wilmore et al⁵² supported feeding regimens with caloric intake as high as 8000 kcal/day. In 1974, Curreri et al⁵³ quantified the calories required to maintain body weight over time, and developed a formula specific to burn patients to calculate energy requirements based on burn size.

Current guidelines recommend a rise in protein provision of at least 50% to 1.5–2.0 g/kg/day for adults and up to 3 g/kg/day for pediatric patients to match the rise in proteolysis.^54,55 The increased intake helps to reduce the negative nitrogen balance but does not prevent catabolism.⁵⁶ Excess provision of protein above the suggested levels has been shown not to block protein breakdown or enhance synthesis, and can result in overfeeding and its associated complications. Improved survival, immune function, and lower rates of bacteremia have also been demonstrated in pediatric burn patients who were fed a diet containing 23% protein.⁵⁷

Energy and protein demands are greatly elevated in burn patients and this should be addressed by calculation of individual requirements and tailoring supplementation to adapt to changing needs. Early and aggressive support with enteral nutrition (EN) has been shown to improve outcomes and should be considered the first choice in suitable patients without contraindications.⁵⁸ Total parenteral nutrition (TPN) involves intravenous infusion of elemental components and bypasses the usual processes of digestion. A central line is required for delivery of hyperosmolar feeding regimens. TPN has declined from its previous popularity and should now be reserved for patients in whom contraindications to EN exist, due to the advantages of EN in terms of cost, reduced complications, and improved outcomes. Supplementation with additional TPN as an adjunct has been associated with substantially increased mortality in patients with burns.^59,60 In contrast to EN, TPN has been associated with increased rates of bacterial translocation.⁶¹

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