Do not Use Parenteral Nutrition, if at all Possible, in Burn Patients

Do not Use Parenteral Nutrition, if at all Possible, in Burn Patients

Jeremy W. Pyle MD

James H. Holmes IV MD

Years of work and hundreds of studies have been performed to elucidate the best and most beneficial means of supplying nutrition to burn patients. Focus in the recent past has shifted from the overall importance of nutrition to a highly specialized and improved collection of recommendations. These include not only what and how much, but also where and when, why and how.

Burn wound pathophysiology and how it affects the body as a whole are fairly well understood, and the degree to which thermal injury alters nutrition requirements is directly related to the total body surface area (TBSA) of the burn. Burn wound derangements include grossly elevated local metabolic needs and increased systemic requirements. The battle to provide adequate nutrition in the face of this alteration has three fronts. First, a burn wound requires ramped-up repair efforts and immune support. Second, the body’s response to the insult includes significant systemic derangements in neuroendocrine and cytokine-mediated processes. Finally, the gastrointestinal tract and its response to these changes are unique and important. Designing a nutrition regimen must address all three of these areas, paying special attention to the carbohydrate and protein requirements needed to avoid muscle and mucosal catabolism and avoiding a heavy reliance on lipids as a source of calories.

What not to Do

Postburn hypermetabolism has been shown to respond to a low-fat, high-protein enteral diet with fewer wound complications and a lower overall morbidity. Conversely, parenteral nutrition has consistently been linked to increased mortality in the burn patient. Burn wounds almost exclusively utilize glucose. This, coupled with the increased overall glucose requirements that come with thermal injury, means that glucose supply must be either increased in the diet or come from the catabolism of other tissues. For this reason, carbohydrates should serve as the major nonprotein source of nutrition. Doing so ensures not only that the wound will be better supplied with energy, but also that the rest of the body operates without quite so severe a demand for
gluconeogenic substrates, and so protein stores can be preserved. If a patient is poorly fed, the end result of this demand in such a patient has an energy deficit that has been shown to develop very early postburn. Hence, early and aggressive feedings are recommended. They have been shown to positively affect protein requirements, energy deficiency, and insulin secretion. Because hyperglycemia and protein malnutrition are well known for their detrimental effects on wound healing, it seems reasonable to assume that increased insulin and a decreased need for endogenous gluconeogenic substrates provide a benefit. Ideal energy balance is met with 5 mg/kg/min of glucose.

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Jul 1, 2016 | Posted by in ANESTHESIA | Comments Off on Do not Use Parenteral Nutrition, if at all Possible, in Burn Patients

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