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Burn injuries in the ICU

A case scenario approach part 2.

Simko, Lynn Coletta PhD, RN, CCRN; Culleiton, Alicia L. DNP, RN, CNE

Lynn Coletta Simko is a clinical associate professor at the Duquesne University School of Nursing, Pittsburgh, Pa.

Alicia L. Culleiton is a practicing educator and clinician in Pittsburgh, Pa.

The authors have disclosed that they have no financial relationships related to this article.

This article is the second part of a case study about Abe, a young Amish patient with severe burn injuries. In Part 1, various types of burns were described, as well as initial resuscitative care for patients with severe burn injuries. In Part 2, the authors detail Abe's unfolding case scenario and conclusion, cultural concerns in nursing care for an Amish patient, and the treatment modalities necessary to manage patients with burn injuries in the ICU.

Part 1 of this two-part series ( Burn injuries in the ICU: A case scenario approach , March 2017) reviewed the various types of burn injuries and what critical care nurses need to know to provide initial resuscitative care for patients with severe burn injuries using the case study of a young Amish boy, Abe. This article is based on Abe's unfolding case scenario and conclusion and describes various treatment modalities necessary to manage the extended care of patients with burn injuries in the ICU. The article also outlines system-based nursing considerations and important cultural aspects of care for members of the Amish community.

Abe's story

Abe is a 14-year-old Amish boy who stoked a fire in a wood-burning stove and was hurt by a subsequent explosion. He was transported by helicopter to the local burn ICU (BICU). He sustained an 82% total body surface area (TBSA) thermal burn (calculated using the Lund-Browder chart). Abe's burns included bilateral full-thickness circumferential burns to his legs and feet, arms and hands, genitalia, and deep partial-thickness burns to his head, neck, and anterior trunk.

Before Abe's arrival to the BICU, the flight team stabilized Abe by initiating cervical spine precautions, endotracheally intubating him, and providing fluid resuscitation and sedation and analgesia with I.V. propofol and morphine via two large-bore peripheral venous catheters.

Once Abe was admitted to the BICU, a right brachial arterial line was placed along with a right internal jugular central venous catheter. Initial I.V. fluid resuscitation was calculated based on Abe's weight of 79 lb (36 kg), a urinary catheter was placed, and a tetanus injection was administered. The morphine drip was discontinued, an I.V. ketamine drip was started, and wound care began.

Upon reassessment, the nursing staff noted that Abe's pedal and radial pulses were absent bilaterally, and emergent bilateral upper and lower extremity escharotomies were performed. At this point of care, Abe's clinical status was critical but stable.

The road to recovery

Once the escharotomies were completed and Abe was stable, an enteral nasogastric tube was placed in the left nares and feedings began. Abe received standard wound dressings with silver sulfadiazine until his burn wounds were grafted (with the exception of his genital burns).

Abe experienced a slow recovery. Within 72 hours of his admission to the BICU, the first surgical excision and grafting on Abe's hands, feet, head, and neck were completed. His anterior trunk also required surgical excision and grafting at this time. Nurses explained to Abe's parents that further excisions and grafting procedures would be performed until all of Abe's burn wounds were closed. The excisions and grafting on Abe's arms and legs were completed over the next month.

A conservative approach was employed to treat Abe's genital burn. Initially, all obvious retained material (loose debridement) and contaminated remnants of Abe's clothing were removed. Next, the BICU nurses completed a prolonged cooling-down procedure with water. During the duration of Abe's admission, topical antibiotic ointments such as mupirocin were impregnated into gauze and applied over the perineal area and changed after every bowel movement. Scheduled and p.r.n. cleansing was accomplished using 4% chlorhexidine skin wash. This approach led to the successful healing of Abe's genital burns.

Abe was weaned from the ventilator on the third attempt during his second week in the BICU, and solid foods were introduced gradually. The following sections expand on Abe's care and address the cardiovascular, respiratory, integumentary, infection, nutrition, mobility, and pain management considerations Abe's nurses had to take into account during his stay in the BICU.

Cardiovascular management

The priority nursing diagnoses for cardiovascular management are decreased cardiac output (CO) related to increased capillary permeability, fluid volume deficit related to loss of plasma from the vascular space, and an alteration in tissue perfusion related to decreased CO and edema.

Fluid resuscitation for Abe was addressed in Part 1 and is based on the TBSA burned as well as his weight and age. Fluids may be titrated to keep the adult patient's urine output at 0.5 mL/kg/h, which is recommended by the American Burn Association. 1,2 Patients with electrical burns and/or inhalation injury may need increased fluid resuscitation. 3

The critical care nurse should monitor the patient's hemodynamic status: urine output, central venous pressure, CO, and mean arterial pressure. 4 Lactated Ringer solution is the crystalloid of choice for the first 24 hours because it contains electrolytes, and lactate may reduce hyperchloremic acidosis, which can occur with the very large volumes of 0.9% sodium chloride solution administered to patients with severe burns. 5 Hypertonic dextrose solutions and colloids may be administered when capillary permeability is restored. After the first 24 hours, colloid-containing solutions can help reduce edema and third-space fluid shifts by increasing oncotic pressure in the intravascular space and pulling fluid from the interstitial space. 3,5

Patients may be placed on digoxin to address myocardial dysfunction and decreased myocardial contractility after a burn injury. 2 Cardiac dysfunction occurs secondary to activation of the complement system, which generates anaphylatoxins. 2 Vasopressors, such as dopamine, also may be needed to help increase the patient's CO. 5 Monitor the patient's cardiac rate and rhythm. Remember that age-related alterations and reduced physiologic reserve put older adults at an increased risk for developing atrial fibrillation after a burn injury. 5

Patients with burn injuries also are at risk for venous thromboembolism (VTE, the umbrella term for deep vein thrombosis [DVT] and pulmonary embolism [PE]), due to endothelial injury, hypercoagulability, and venous stasis. DVT occurs in 1% to 23% of patients with burn injuries. 2

Abe developed a right lower extremity DVT in the BICU even though he was prescribed SQ heparin twice daily. Given the extent of his injuries and the amount of grafting remaining, the burn surgeon decided to insert a retrievable inferior vena cava filter. 6 This was done to help prevent Abe from suffering a PE. The filter was removed prior to discharge.

Administer VTE prophylaxis as prescribed; intermittent pneumatic compression and low-molecular-weight heparin are typically used. If the patients' legs are edematous from a burn injury, assessing leg edema from DVT is difficult. Further, pain can mask the patient's discomfort from a DVT, so look for signs and symptoms of a PE, including dyspnea and sudden shortness of breath. 2

If the patient has circumferential burns of the chest, abdomen, or extremities, like Abe, an emergency decompressive escharotomy may be needed to accommodate tissue edema or relieve mechanical constriction interfering with respiration. The eschar in a circumferential burn can compress the blood vessels in an extremity, decreasing distal perfusion. If the abdomen or thorax is involved, an abdominal compartment syndrome can develop along with decreased lung expansion. The escharotomy is done at the bedside and does not require analgesia because this dead tissue has no nerve endings. 5 In addition, eschar is avascular, so blood loss is minimal. In some patients, a fasciotomy (incision down to the muscle fascia) may be needed. 2 Postponing necessary escharotomies can result in limb loss and respiratory arrest. 4

Respiratory management

A priority nursing diagnosis involving the respiratory system is ineffective breathing pattern related to inhalation injury and airway obstruction. As discussed in Part 1, the signs and symptoms of inhalation injury include facial burns, hoarseness, soot in the nose or mouth, carbon in the sputum, lip edema, and singed eyebrows or nasal hair. 2

Fiberoptic bronchoscopy is a simple, accurate, and safe method of diagnosing acute inhalation injury. 2,7 It also allows for oxygen delivery, deep suctioning, and removal of necrotic tissue. The endotracheal tube should be secured without putting pressure on the ears or other burned areas. The head of the bed should be elevated to decrease airway and facial edema from fluid resuscitation, unless medically contraindicated. 2

When patients with burn injuries are admitted to the ED or the ICU, plan to obtain a chest X-ray and sputum culture and sensitivity. Typically, patients with an inhalation injury are intubated and placed on mechanical ventilation. Aim to maintain a PaO 2 over 90 mm Hg and an SaO 2 over 95%. 2 Because these patients' carboxyhemoglobin (COHb) levels typically are elevated due to the inhalation of carbon monoxide, they will receive 100% oxygen until their COHb level is 5% to 10% or lower. 2

Hyperbaric oxygen therapy (HBOT) may be indicated for some patients; this treatment displaces carbon monoxide from intracellular stores and may improve mitochondrial function. 8 HBOT should be considered in patients with COHb levels greater than 40%, who are unresponsive, have other neurologic deficits, or have severe metabolic acidosis (pH less than 7.1). 8

Patients with inhalation injury also are treated for cyanide poisoning because of the number of household synthetics (such as upholstered furniture, window coverings, plastics, vinyl flooring) that, when combusted, produce cyanide. Cyanide, one of the toxins released when these products burn, inhibits intracellular respiration and oxygen utilization. Cyanide binds with cytochrome oxidase, which is in high concentrations in the mitochondria. This decreases cell metabolism and adenosine triphosphate, which then causes a shift from aerobic to anaerobic metabolism. Anaerobic metabolism leads to lactic acidosis and cell death. 2 The liver detoxifies cyanide to thiocyanate, which is excreted by the kidneys. Although it will not reverse cyanide poisoning, 100% oxygen is an important intervention for all patients involved in enclosed-space fires. Antidotes for cyanide poisoning such as hydroxocobalamin should be given by I.V. infusion. 2 Patients with acute kidney injury may need hemodialysis.

Patients who were taking corticosteroids before the injury may experience adrenal insufficiency and should receive stress doses of corticosteroids. Bronchodilators may also be used to reverse bronchospasms. 5,9

Patients with severe inhalation injury may need extracorporeal membrane oxygenation (ECMO), in which blood is oxygenated via machine before being returned to the body. By taking over lung function, ECMO lets the lungs heal. (See Extracorporeal membrane oxygenation: A review in our July 2017 issue.) Patients who develop acute respiratory distress syndrome may need a neuromuscular blocking drug such as cisatracurium to allow uninterrupted ventilation and better gas exchange. 2,5,7

Although most pulmonary damage is self-limited and resolves in 2 to 3 days, patients with inhalation injuries may need a tracheostomy with prolonged mechanical ventilation or at the surgeon's discretion. 3,5 In the past, tracheostomy was discouraged because of potential pulmonary contamination with burn wound bacterial flora. But advances in burn care have decreased the risk of pneumonia associated with tracheostomy in patients with burn injury. 2,10

Nursing care includes meticulous pulmonary hygiene to decrease the patient's risk of ventilator-associated pneumonia (VAP). Interventions to decrease VAP risk include regular oral care, eliminating cross-contamination when suctioning, glove use, elevating the head of the bed 30 to 45 degrees unless medically contraindicated, and use of a secretion evacuation port on the endotracheal tube or tracheostomy. Also assess the patient's breath sounds, and monitor for tachypnea, fever, leukocytosis, pulmonary infiltrates, and purulent secretions. 2 Turn and reposition the patient at least every 2 hours, perform chest physical therapy, and encourage ambulation.

Abe experienced an inhalation injury and was intubated on a ventilator for 2 weeks. He also had difficulty with extubation, and to help decrease the complications of immobility he was ambulated to a bedside chair while intubated on mechanical ventilation.

Integumentary management

Integumentary management includes restoring skin integrity and preventing skin loss. Once successfully resuscitated, patients with larger burns begin a period of chronic inflammation, hypermetabolism, and lean body mass wasting, all of which can prolong and impair wound healing. 11

Debridement . A major focus of burn wound management is debridement, which removes eschar and other cellular debris from the wound to promote skin restoration by natural wound healing or grafts. Debridement methods include mechanical, enzymatic, surgical, and autolytic methods.

When Abe initially presented to the BICU, mechanical debridement was completed on all of his burn wounds. Mechanical debridement is often done via hydrotherapy, which is defined as application of water for therapy. 2,5 Shower trolleys are used to let water flow over the burn wound and immediately drain away, or alternatively, wounds are cleansed at the bedside with water. It is no longer recommended that patients be immersed in a tube or whirlpool as this increases the risk of infection. 5 Hydrotherapy allows for visualization and cleansing of the burn wound. During this therapy, previously applied topical agents, exudate, necrotic tissue, and fibrous debris are removed from the wound to expose healthy tissue.

Other methods of mechanical debridement include wet-to-dry dressings. Because mechanical debridement may damage newly formed viable tissue, this method is most often effective for large areas of unhealthy tissue when used with discretion. 12

Enzymatic debridement can occur naturally by autolysis or by applying topical proteolytic enzyme ointments that digest necrotic tissue. Enzymatic debridement is usually performed on deep partial- or full-thickness burns that cover a small area. 2,5

Surgical debridement is done early in the burn rehabilitation process, typically 1 to 3 days postinjury. Performed in the OR, surgical debridement involves excising necrotic tissue until brisk punctate bleeding occurs, indicating a wound that is ready to be grafted. 13

Surgical debridement can cause a great deal of blood loss, yet the literature discourages aggressive transfusions. 13 Current recommendations for a patient with a burn injury not at considerable risk for acute coronary syndrome (ACS) include transfusion of two units of packed red blood cells only if the hemoglobin falls below 8 g/dL. In contrast, for patients at risk for ACS, use a transfusion threshold of 10 g/dL. 13

Autolytic debridement is a process in which the body uses its own wound fluids to digest necrotic tissues. The process promotes the application of a moisture-retentive dressing, which is left in place for several days. The wound fluid trapped beneath the dressing softens and liquefies the necrotic tissue, while growth factors and inflammatory cells within the wound encourage and hasten the early phases of wound healing. 2,5

Prior to any type of wound cleansing and/or debridement, explain the procedure to the patient and family. The room temperature should be maintained between 85° F and 90° F (29.4° C and 32.2° C) to prevent excessive body heat loss and chilling. Analgesia and/or anxiolytics must be administered prior to the procedure per healthcare provider order or hospital protocol. In addition, techniques such as hypnosis, massage, relaxation, distraction, music therapy, and guided imagery may be useful adjuncts for reducing anxiety and enhancing pain relief. Any hair noted around the wound should be shaved, with careful attention not to shave the eyebrows. 2,5

Dressings . Various dressings may be used after the wound is cleansed, such as standard wound dressings and biologic, biosynthetic, and synthetic dressings.

The standard wound dressing involves applying a thin layer of a topical antimicrobial agent to the area, covering the wound with a fine, nonadherent mesh gauze, and holding the gauze in place with either a tubular net bandage or gauze wraps. Common topical antimicrobial agents include, but are not limited to, silver sulfadiazine, mafenide acetate, and silver nitrate. 5 Silver sulfadiazine use is contraindicated in patients with a sulfa allergy. Following the application of silver sulfadiazine, the patient is at risk for the development of leukopenia. 2,5 Therefore, the nurse should monitor the patient's white blood cell count.

Burn wounds may be left open to air after an antimicrobial agent is applied (open method) or covered with a gauze dressing immediately after the agent is applied (closed method). Another variation of the closed method is the application of gauze dressing soaked with a topical antimicrobial agent.

Biologic dressings protect granulation tissue in patients with healing partial-thickness burns, and granulating, clean, eschar-free full-thickness wounds. They also are used as a temporary skin cover to decrease infection, heat loss, and pain. These dressings are skin or membranes collected from human tissue donors (homografts) or animals (heterografts; see the section on grafting, below).

Biosynthetic dressings (a combination of biologic and synthetic materials) are commonly used to cover superficial burns and partial-thickness burn areas. They are made up of nylon fabric that is partially embedded into a silicone film. Collagen is incorporated into both components, and when the nylon is applied to the wound surface it adheres and promotes epithelialization.

Synthetic dressings are made up of solid silicone and plastic membranes and are used to cover donor sites. This type of dressing is applied to a prepared wound and remains intact until it falls off or is removed.

Grafting . As previously discussed, the depth of the burn injury will determine whether skin grafting is required. Full-thickness and deep partial-thickness burns require grafting. Skin grafting is the process of placing skin on a healthy, well-vascularized burn wound bed. Prior to grafting, the necrotic tissue of the burn wound is surgically removed. Grafts are usually secured to the burn wound by surgical staples, dressed, and the affected area kept immobile for 3 to 5 days. Several types of skin can be used for grafting: homografts, heterografts, or autografts. 2,5

Homografts , also called allografts, are obtained from cadavers via skin banks. Disadvantages associated with homografts include their high cost and the potential to transmit infection. In contrast, heterografts , or xenografts, are most commonly obtained from an animal such as a pig.

Autografts are the only permanent type of skin grafting. They are transplanted skin from unburned areas on the patient's body used as wound coverings. The unburned areas where the skin is removed are referred to as donor sites, which can be reharvested once they have healed. 2,5

Common nursing care for all graft sites includes immobilizing and/or splinting the grafted site and elevating grafted extremities. Initial and subsequent graft dressing changes are completed per the healthcare provider orders. Once the dressings are removed, the nurse should apply basic wound care knowledge and principles to evaluate and care for the wound. All graft sites should be monitored for nonvascularization, nonadherence, infection, and graft necrosis. 2,5

Abe underwent many surgical excisions and grafting procedures. Initially, autografts were applied to Abe's hands, feet, head, and neck. Skin was harvested from Abe's back (donor site) and heterografts were applied until his donor site could heal. As the weeks went by, Abe returned multiple times to the OR to have the burns on his arms and legs grafted.

Following surgery, the graft sites were dressed with bulky cotton dressings and left in place for 5 days to permit vascularization of the newly grafted skin. Abe's limbs were immobilized/splinted to prevent movement and shearing, and to promote graft adherence. Abe's extremities were elevated to prevent pooling of blood and edema formation that could lead to increased pressure and graft loss.

After the dressings were removed, Abe's graft sites were inspected for pockets of serous/serosanguineous fluid that could compromise graft adherence. His left foot graft was found to contain fluid, which was evacuated by needle aspiration and rolling a cotton tip applicator over the graft toward the skin edges. Following these interventions, the graft remained viable.

Abe's donor site offered unique challenges for the nursing staff. When grafting procedures are completed on the posterior of the body, or the donor sites involve the posterior body, the patient must remain immobilized for 7 to 10 days in a prone or side-lying position. After 2 days in the side-lying position being repositioned every 2 hours, the nursing staff placed Abe on an air-fluidized and low air loss bed to reduce donor-site ischemia and prevent skin breakdown and pressure injuries. 14

Infection management

The primary risk for infection is related to altered skin integrity and immunosuppression. Patients with severe burns are at a high risk for infection, especially drug-resistant infection. 15 Drug-resistant infection can lead to longer hospital admission stays, delayed wound healing, higher costs, and higher mortality. 16

Assess burns frequently for signs of infection and dysfunctional wound healing. Patients with extensive burns are considered immunosuppressed because the burn destroys the skin barrier to pathogens, and cytokine and neutrophil activity are altered. Pathogens can colonize burn eschar and enter the tissues, causing secondary bacteremia. 5 Localized signs and symptoms of burn wound infection include conversion of a partial-thickness injury to a full-thickness wound, eschar separation, worsening cellulitis of surrounding normal tissue, and tissue necrosis. 17

Infection often leads to a pronounced immune response, accompanied by sepsis or septic shock. Resultant hypotension and impaired perfusion of the end organs, including the skin, prolong wound healing. The leading causes of death following a severe burn are multiorgan failure and sepsis. 18

Sources of infection are invasive monitoring, peripheral and central venous catheters, urinary catheters, endotracheal tubes, and treatments such as debridement. These interventions may be a necessary adjunct to the patient's medical regimen. Maintain sterile technique during invasive and wound care procedures to decrease the risk of infection. (See Fighting infection .)

To avoid encouraging antibiotic resistance, healthcare providers rarely prescribe prophylactic antibiotics for patients with burn injuries. Systemic antibiotics are prescribed and administered only for patients with documented wound infection or other positive culture. 19

Nutrition management

The priority nursing diagnosis for nutrition management is nutrition imbalance related to increased metabolic demands from stress and the physiologic demands of wound healing. 2,5 The patient's resting energy expenditure can be double its normal level because of heat loss from the burn wound, pain, infection, and an increase in beta-adrenergic activity. 5 Some patients may need 4,000 to 6,000 kcal per day. The patient's daily estimated caloric needs should be regularly calculated by a dietitian and readjusted as the patient's condition warrants. The goals of care are to provide optimal nutrition, maintain skeletal muscle, prevent weight loss, promote wound healing and graft adherence, prevent sepsis, and achieve an anabolic state and positive nitrogen balance.

Patients with burn injuries have hyperdynamic circulatory, physiologic, catabolic, and immune system responses. Muscle wasting, increased body temperature, increased infection risk, and peripheral insulin resistance are some characteristics of this hypermetabolic state, which begins within 5 days of a major burn injury and can last as long as 3 years. Persistent elevations of stress mediators such as serum cytokines, catecholamines, and basal energy requirements, as well as impaired glucose metabolism and insulin sensitivity, also may persist for up to 3 years after a severe burn injury. 2,5

Nutrition (enteral, parenteral, or a combination) generally is initiated immediately or 24 to 72 hours postinjury. For enteral feedings, a nasointestinal feeding tube is placed under fluoroscopy into the duodenum or jejunum; the tip of the tube should extend past the pyloric sphincter to prevent reflux and aspiration. Enteral feedings are contraindicated if the patient has a Curling ulcer, bowel obstruction, septic ileus, pancreatitis, intra-abdominal hypertension, or a feeding intolerance. 2,5

Parenteral nutrition is only started when the enteral route cannot be used. Specific indications for parenteral nutrition include inadequate enteral intake because of clinical status, weight loss greater than 10% of normal body weight, prolonged wound exposure, or debilitated condition before injury. 4 When the patient can tolerate an oral diet, a high-calorie, high-protein diet with vitamin and mineral supplements should be prescribed.

Monitor the patient for evidence of enteral feeding intolerance such as diarrhea, constipation, emesis, excessive gastric residual, increased abdominal pressure, and/or abdominal distension. Weigh the patient daily, and monitor serum protein, iron, glucose, and albumin levels. Subtherapeutic values indicate inadequate nutritional intake. 11 Among nonnutrition treatments, research findings support the use of propranolol, a beta blocker, to spare muscle tissue and reduce the patient's heart rate, and it is considered standard of care for patients with burns. 20

Abe was given enteral nasogastric tube feedings upon admission to the BICU. On day 2 he was taken to interventional radiology and a nasoduodenal tube was inserted into his duodenum and secured by a nasal bridle clip. Once extubated he was started on an oral high-calorie, high-protein diet with vitamin and mineral supplements along with enteral tube feedings.

Mobility management

Patients with burns may experience impaired physical mobility and an inability to perform self-care related to contractures, splinting, or immobilization after skin grafts. As burn wounds heal, contractures can develop and significantly limit mobility, especially if a joint is involved. 2,5 Patients with burns also may experience permanent physical changes that can affect their psychosocial status (see Understanding body image issues ). Patient-care goals are to avoid permanent joint dysfunction and return patients to their normal routine with no or few adjustments.

Physical therapy should begin at the early stages of treatment, with ambulation and a planned exercise regimen starting as soon as the patient's condition stabilizes. Exercises should help patients to regain their strength and endurance, and balance needed for activities such as standing, getting into a chair, and early ambulation after the wounds are closed. Intervene to prevent contracture development and implement measures to decrease edema such as elevating burned extremities. Nurses can also facilitate mobility by optimizing pain management (see the next section). 2,5,21

Occupational therapists can help prevent deformities and contractures with the use of passive and active range of motion (ROM) exercises, elevation of the limbs, use of wedges and splints to prevent edema, scar management, and assisting the patient to perform activities of daily living (ADL). 21

There is debate as to which treatment(s)—pressure treatment garments, 3D-printed transparent facemasks, and/or use of fractional CO 2 laser treatment for mature burn scars, and so on—are the best therapy to help decrease scarring. More randomized trials need to be conducted to inform evidence-based practice. 22-24

Nursing interventions associated with mobility include performing active and passive ROM exercises on all joints, maintaining limbs in functional alignment, early ambulation, and applying splints as directed while monitoring the splinted area for vascular compromise, nerve compression, and skin breakdown.

Other interventions used to combat the complications of immobility include deep-breathing exercises, use of an incentive spirometer, turning, and proper positioning to prevent atelectasis and pneumonia. 25

Abe experienced difficulty with extremity movement and his ADL. For the first 4 to 6 weeks he could not feed himself because of his hand grafts and the splints placed on his hands and fingers. Once the splints were removed and he had complete ROM in his wrists and hands, he began to participate in his ADL with the help of an occupational therapist.

Pain management

Patients may have acute pain related to burn injury and treatments, and related to the exposed nerve endings in damaged dermis. Assess the patient's need for and response to pain medication, with the ultimate goal of the patient reporting pain relief and satisfaction with the level of pain control. Pain can be: 5

• background: pain that is present while the patient is in a resting state, and is of lower intensity and longer duration than acute pain.
• procedural: an intense, short-lived pain produced by wound care, activities, or therapies.
• breakthrough: pain that breaks through the ongoing treatment for persistent pain.

General nursing interventions associated with each type, phase, or stage include using a reliable pain intensity rating tool, administering analgesics before performing painful procedures, administering I.V. analgesics as prescribed, explaining all procedures and the expected associated level of discomfort beforehand, using nonpharmacologic methods of pain management such as guided imagery, music therapy, and meditation in combination with analgesics and/or anxiolytics, and encouraging patients to verbalize their pain experience.

I.V. analgesia is recommended during the acute postburn period because shock or paralytic ileus can impair gastrointestinal function. 5 Avoid I.M. injections because the medication often is not absorbed adequately in burned or edematous areas, and can pool in the tissues. When fluid mobilization begins, the patient may be inadvertently over- or undermedicated from the interstitial accumulation of previously received I.M. injections. 2,5

A variety of analgesics are used for patients with burn injuries; however, I.V. morphine is the drug of choice. 2 Remember that depending on the severity and extent of the injury, these patients may require much higher doses compared with other patients. 13 In the case of central nervous system depression from a morphine overdose, administer naloxone, an opioid-receptor antagonist. 26

Continuous I.V. infusions of morphine are reserved for patients with severe burns who need mechanical ventilation. Morphine may be delivered via a patient-controlled analgesia (PCA) pump for severe background pain. The PCA pump is ideal for patients who are neurologically intact and can actively participate in their pain management. Mild-to-moderate background pain can be treated with oral oxycodone and acetaminophen in patients who are hemodynamically stable and without an ileus.

Because patients with burns usually receive higher-than-normal morphine dosages, closely monitor their vital signs, level of consciousness, respiratory rate and rhythm, end-tidal carbon dioxide levels, and oxygen saturation. 26 Be alert for signs and symptoms of opioid-induced sedation, respiratory depression, and hypotension, and have emergency equipment readily available. Morphine-induced hypotension may occur in patients who have hypovolemia secondary to burn shock or sepsis.

Abe did not respond well to the standard doses of morphine; it did not provide him with adequate analgesia. His healthcare provider ordered a low-dose ketamine infusion in combination with an I.V. infusion of propofol. Ketamine, a nonbarbiturate general anesthetic agent, can be used to provide adequate levels of analgesia for burn wound care. 27 It can also be successfully used for bedside sedation procedures. The literature shows that a combination of ketamine and propofol can provide better relief than morphine for some patients, and is a worthy treatment choice for pain during burn dressing changes as noted in Abe's care. 28

Cultural considerations

Many cultural considerations came into play throughout Abe's hospitalization. For example, education ends at the eighth grade in the Amish community (age 14 years). Amish children then enter the workforce, which is mostly farming. Thus, when interacting with the Amish patient, nurses should use age-appropriate language and educational material. 29

The Amish devote their entire life to God. As in the case of Abe's family, most Amish avoid modern conveniences such as telephones, electricity, hot water lines, or bathtubs, and their most common mode of transportation is a horse and buggy. These restrictions affected Abe's family as they related to communication with the healthcare team, and the parents' ability to stay with Abe throughout his hospitalization. After much back-and-forth with the hospital social worker and the leaders of Abe's community, it was decided Abe's family could be provided with a hospital track phone and stay in provided hospital housing. This was necessary for them to actively participate in Abe's extended plan of care. 29

The Amish do not have health insurance. They feel that it is a worldly product and purchasing it shows a lack of faith in God. The Amish prefer to use folk medicine (faith healing, herbal treatments, and vitamins). However, each Amish family contributes a predetermined amount of money to a community fund on a regular basis for community needs such as healthcare expenses. The church elders in Abe's community agreed to pay for Abe's hospital costs. Costs were mitigated by a discount offered by hospital representatives after negotiations with Abe's community leaders. 29

These examples only scratch the surface of cultural considerations when caring for an Amish community member. Given the extended hospitalization of a burn injury patient, it is the healthcare team's responsibility to take a holistic approach that ensures a hospital course that meets each individual patient's specific needs.

Throughout Abe's hospitalization, he had a very positive outlook and relied on his Amish upbringing for his spiritual strength. During the 18 weeks of his hospitalization his father, mother, aunts, and community members were either visiting, in the waiting room of the BICU, or in hospital housing nearby.

By the 18th week of his hospitalization, Abe's grafting procedures were complete, and he was discharged from the hospital. The interdisciplinary team, in tandem with the hospital's social worker, developed a rehabilitation plan for Abe to receive physical and occupational therapy at home, as well as twice-weekly visits by a home healthcare nurse.

Abe left the hospital with the ability to walk and perform all of his ADL. Abe was fitted with compression garments and completed all the physical and occupational activities as prescribed.

Fighting infection 2,5,15

• Monitor the burn wound daily for general signs and symptoms of infection. Remove all topical medications and wound exudate so the entire wound can be visualized.
• Culture all body secretions and wounds as indicated.
• Administer antimicrobial therapies as prescribed, based on culture and sensitivity results.
• Monitor blood culture results for possible bacteremia.
• Assure that the patient is up-to-date with tetanus immunization; patients with severe burns are at risk for anaerobic infection caused by Clostridium tetani .
• Monitor white blood cell counts and report leukocytosis, which may indicate infection.
• Monitor vital signs as prescribed, remembering that fever in the absence of other signs and symptoms of infection does not indicate infection. Patients with burn injuries have a hypermetabolic response that automatically increases their core temperature (often to 101.3° F [38.5 °C]).
• Monitor for signs and symptoms of pneumonia. Wean patients from the ventilator as soon as possible.
• Maintain appropriate nutritional support.
• Maintain an aseptic environment at all times, and use standard precautions and sterile technique for procedures when indicated.
• Avoid cross-contamination during wound care. Wear a cap, mask, protective eye wear, gown, and gloves; perform hand hygiene before and after contact; expose, clean, and rewrap uninfected areas first.
• Be aware that cross-contamination can occur from the air, healthcare providers, and visitors. Visitors who are ill should not be permitted to see the patient.
• Avoid autocontamination from the oropharynx, fecal flora, and unburned skin.

Understanding body image issues

Patients with burn injuries can suffer profound losses. These may include an inability to work, loss of personal property, loved ones, and their home. 28 As a result, nurses should continually assess the patient's psychosocial status. Consider asking the following questions:

• What are your concerns or fears?
• Are you afraid of pain or changes in physical appearance?
• Do you feel powerless?
• Are you afraid of being rejected by family and loved ones?
• Do you have concerns or fears concerning sexual function?

An important goal of care is for patients to adapt to their altered body. Assess patient response to changes based on their ability to verbalize feelings related to changes in physical appearance, interest in resources that may improve function and appearance (such as wigs, cosmetics, and prostheses), and readiness to socialize with family and usual social groups. Being aware of patient anxieties and fears will better prepare nurses to provide support and request referrals specific to patient needs.

Amish; burn ICU; critical care; cultural competency; severe burn injuries; thermal burns; trauma; wound care

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Fatima, a single 32-year-old Muslim refugee female, has been living in the United State for six months with her two kids in a garage. She was cooking dinner to break her fast during Ramadan when a gas leak resulted in a explosion. Her kids were out playing in the front yard when they heard the explosion. Her eldest daughter immediately ran to her neighbor’s house and asked them to call 911. Upon arrival to the scene, firefighters rescued Fatima and emergency medical technicians (EMTs) were able to remove her burned clothing and hijab. She was conscious, alert and oriented, but sustained significant burn injuries to her face, neck, anterior torso, bilateral upper and lower extremities, and posterior trunk. As a result, the patient was intubated with 100% oxygen enroute to the hospital for airway protection due to inhalation injury and edema with facial burns. The EMTs started an 18 gauge in the left forearm and initiated an intravenous (IV) 1000 mL bolus of Lactated Ringer’s (LR).

Emergency Department (ED)

The EMTs radioed in their ETA at 10 minutes out and the West Hills trauma medical term and burn nurses were informed. Initial assessment at the hospital revealed a young woman that was orally intubated with bilateral clear breath sounds.

Vital signs were as followed:

• Heart Rate: 120
• Blood Pressure: 160/90 (113)
• Temperature: 98.4 F, 36.9 C
• Pain: 4 points on CPOT
• Respirations: 18 (AC ventilation)

The sustained burns to the face, neck, anterior torso, bilateral upper and lower extremities, and posterior trunk were classified as third degree burns to 51% of her total body surface area (TBSA). A chest X-ray confirmed accurate placement of the ET tube. Fluid resuscitation was continued in the ED with LR. The following initial pending labs were drawn: CBC, carboxyhemoglobin, electrolytes, and ABGs. A foley catheter was inserted to monitor renal function (Hinkle & Cheever, 2014).

Burn Intensive Care Unit (BICU)

Fatima was transferred to the BICU where fluid resuscitation was continued. Her reported height and weight in the ED was 157 cm and 50 kg. The Parkland Formula (4mL x % TBSA x kg = total fluid for the first 24 hours) was calculated to a total of 10,200 mL/24 hours (Mehta & Tudor, 2019). The first half of the fluids were administered within the first eight hours totaling 5,100 mL. The second half of the fluid was given over 318.8 mL/hour for a total of 16 hours.

Vitals signs were as followed:

• Heart Rate: 115
• Blood Pressure: 100/80 (90)
• Temperature: 96.o F, 35.6 C
• Pain: 3 points on CPOT
• Respirations: 17 (AC ventilation)

Hourly vital signs were documented. A continuous Dilaudid drip of 1 mg/hr was provided for pain management (Unbound Medicine, 2017). Fatima was assessed for any signs and symptoms of respiratory distress (labored breathing, pallor, hypotension, tachycardia, wheezing). A nasogastric tube (NG) tube was placed for nutritional needs. Urine output during was 40 mL/hr. The lab results revealed the following: K+ 5.3 mEq/L, Na+ 130 mEq/L, Cl+ 111 mEq/L, and glucose 120 mg/dL. Fatima was in a metabolic acidotic state. Her carboxyblin was at 11%.

While in the BICU, Fatima recieved multidisciplinary care from nutrition services, respiratory therapy, spiritual care services, physical therapy, social work, case management, nursing, and the physician team. Once the patient was stable, she underwent serial surgical debridement. The health care team members proposed a porcine xenograft as part of Fatima’s plan of care; however, due to conflicting Islamic religious beliefs the plan of care was revised. After consulting with Fatima and the Mullah (Islamic spiritual leader) they both agreed to a Halal bovine xenograft for treatment. It is important to note that the patient with continue to undergo wound preparation procedures over the next couple of weeks. Due to the %TBSA, the team and Fatima decided to culture epidermal autographs for the optimal skin/wound healing. The nurses and physicians continued to provide aseptic would and graft care (Hinkle & Cheever, 2014).

• Why is it critical to initiate fluid resuscitation in burn patients?
• How would you address Fatima’s cultural beliefs and what type of support systems could be integrated into the patient’s plan of care?
• Fatima had a 51 %TBSA, why is it important to calculate the TBSA in burn patients?
• Burn patients tend to have third-spacing and re at an increased risk for shock and hypothermia. Therefore, it is critical to administer isotonic fluids (preferably Lactated Ringer’s) to replace the fluid loss. Continually assess the patient for signs and symptoms of hypovolemia and ensure they have adequate cardiac output and tissue perfusion.
• As the nurse, it is vital to educate themselves about the patient’s Islamic values, beliefs, and preferences. Attempt to reach out to family members or the community members within the same Mosque. In addition, ensure that a spiritual team is on board. Lastly, communicate with the patient and family to address their wishes, cultural, and religious beliefs in the overall plan of care.
• %TBSA helps determine the amount of fluid resuscitation and the extent of care that is needed. There is an increase chance of mortality with %TBSA greater than 50 because of the increased number of organs involved.

Critical Illness, brain Dysfunction, and Survivorship Center. (2019). Assess, prevent and manage pain. Retrieved from https://www.icudelirium.org/medical-professionals/assess-prevent-and-manage-pain

Hinkle, J.L., & Cheever, K.H. (2014). Brunner & Suddarth’s textbook of medical surgical nursing. Philadelphia, PA: Lippincott Williams & Wilkins

Litt, J.S. (2018). Evaluation and management of the burn patient: A case study and review. Missouri Medicine, 115 (5), 443-446. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6205272/

Mehta, M & Tudor, G.J. (2019) Parkland formula. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK537190/

Strauss, S. & Gillespie, G.L. (2018). Initial assessment and management of burn patients. American Nurse Association, 13 (6). Retrieved from https://www.americannursetoday.com/initial-assessment-mgmt-burn-patients/

Unbound Medicine, Inc. (2017). Nursing Central (1.31). [Mobile application software]. Retrieved from https://itunes.apple.com/us/app/nursing-central/id300420397?mt=8

University of Wisconsin Hospitals and Clinics. (2019). Emergency Medicine. UW Health. Retrieved from https://www.uwhealth.org/emergency-room/assessing-burns-and-planning-resuscitation-the-rule-of-nines/12698

Nursing Case Studies by and for Student Nurses Copyright © by jaimehannans is licensed under a Creative Commons Attribution-NonCommercial 4.0 International License , except where otherwise noted.

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• Published: 17 April 2017

Nutrition and metabolism in burn patients

• Audra Clark   ORCID: orcid.org/0000-0002-8226-5154 1 ,
• Jonathan Imran 1 ,
• Tarik Madni 1 &
• Steven E. Wolf 1  

Burns & Trauma volume  5 , Article number:  11 ( 2017 ) Cite this article

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Severe burn causes significant metabolic derangements that make nutritional support uniquely important and challenging for burned patients. Burn injury causes a persistent and prolonged hypermetabolic state and increased catabolism that results in increased muscle wasting and cachexia. Metabolic rates of burn patients can surpass twice normal, and failure to fulfill these energy requirements causes impaired wound healing, organ dysfunction, and susceptibility to infection. Adequate assessment and provision of nutritional needs is imperative to care for these patients. There is no consensus regarding the optimal timing, route, amount, and composition of nutritional support for burn patients, but most clinicians advocate for early enteral nutrition with high-carbohydrate formulas.

Nutritional support must be individualized, monitored, and adjusted throughout recovery. Further investigation is needed regarding optimal nutritional support and accurate nutritional endpoints and goals.

Nutritional support is a critical aspect of the treatment of burn patients. The metabolic rate of these patients can be greater than twice the normal rate, and this response can last for more than a year after the injury [ 1 , 2 ]. Severe catabolism accompanies the hypermetabolic state and leads to a tremendous loss of lean body mass as well as a decline of host immune function [ 3 ]. Significant nutritional support to meet increased energy expenditure is vital for burn patients’ survival. Unfortunately, our knowledge regarding the complicated physiology of nutrition is incomplete and nutritional regimens vary widely between individual centers. Many questions still exist concerning the optimal route, volume, and composition of diet in the burn population. This article will review the current state of nutrition after burn injury.

The hypermetabolic state

Severe burns cause a profound pathophysiological stress response and a radically increased metabolic rate that can persist for years after injury. Trauma and sepsis also result in hypermetabolism, although to a much lesser degree and for a significantly shorter duration (Fig.  1 ). Immediately after severe injury, patients have a period of decreased metabolism and reduced tissue perfusion known as the “ebb” phase. Soon after, they enter the phase of hypermetabolic rates and hyperdynamic circulation, referred to as the “flow” state [ 4 ]. This hypermetabolic state reflects an increase in whole-body oxygen consumption, and a patient is usually considered hypermetabolic when resting energy expenditure (REE) is more than 10% above normal [ 5 ]. In the acute postburn injury phase, patients with a burn that covers greater than 40% of total body surface area (TBSA) have a REE between 40 and 100% above normal [ 6 , 7 ]. It is important to mitigate this stress response and support the significantly increased metabolic needs of the patient as unchecked hypermetabolism results in an enormous loss of lean muscle mass, immune compromise, and delayed wound healing.

Hypermetabolic response after severe burn, trauma, and sepsis. Adapted from references [ 5 , 6 , 123 , 124 ]

Hypermetabolism after burn is very complicated and not yet fully understood. The underlying mechanisms of this vast metabolic, hormonal, and inflammatory dysregulation are still being actively investigated. At a cellular level, increased whole-body oxygen consumption supports greater adenosine triphosphate (ATP) turnover and thermogenesis. ATP-consuming reactions represent an estimated 57% of the hypermetabolic response to burns, including ATP turnover for protein synthesis, ATP production for hepatic gluconeogenesis, and the cycling of glucose and fatty acids [ 8 ]. Because ATP turnover does not completely account for burn-induced hypermetabolism, it implies that mitochondrial oxygen consumption exceeds ATP production after severe burn. This likely occurs via the uncoupling of mitochondrial respiration from ADP phosphorylation resulting in heat production [ 5 ]. This theory is supported by the recent finding that uncoupling protein 1 (UCP1), a mitochondrial transmembrane protein and a principal mediator of thermogenesis, is much more abundant in the adipose tissue of burn patients compared to healthy individuals [ 9 , 10 ].

Several studies implicate catecholamines as a primary mediator of hypermetabolism [ 11 , 12 ]. The elevation of catabolic hormones epinephrine, cortisol, and glucagon lead to the inhibition of protein synthesis and lipogenesis [ 13 ]. Protein breakdown becomes a necessary and large source of energy, and skeletal muscle cachexia results from a long-lasting imbalance between protein synthesis and breakdown. The dysregulation of skeletal muscle kinetics lasts a year or more after severe burn, and reduced lean body mass is reported in patients up to 3 years after injury [ 14 – 16 ].

Adequate and prompt nutrition is extremely important for preventing numerous complications, although nutrition has a complex relationship with the hypermetabolic state. In animal models, early nutrition, usually defined as within 24 h of injury, has been shown to actually mitigate burn-induced hypercatabolism and hypermetabolism, although data in humans have not borne this out [ 17 , 18 ]. A study by Hart et al. compared burned children who had early aggressive feeding and wound excision to burned children who had delay to this treatment, with the authors expecting to find that early surgical treatment and aggressive enteral nutritional support would limit the hypermetabolic response to burn. Surprisingly, they found that the late treatment cohort had significantly lower energy expenditure than the early treatment group. Furthermore, the children with delayed nutrition and surgical excision had a significant increase in their energy expenditure after the initiation of therapy. The authors concluded that excision and aggressive feeding are requisite for the full expression of burn-induced hypermetabolism. Muscle protein catabolism, on the other hand, was significantly decreased in the patients who received early treatment [ 19 ]. Burn patients are in a catabolic state that can lead to significant weight loss and associated complications. A 10% loss of total body mass leads to immune dysfunction, 20% to impaired wound healing, 30% to severe infections, and 40% to mortality [ 20 ]. Early enteral feeding does result in improved muscle mass maintenance, the modulation of stress hormone levels, improved gut mucosal integrity, improved wound healing, decreased risk of Curling ulcer formation, and shorter intensive care unit stay and is therefore universally recommended despite its link to the hypermetabolic state [ 21 , 22 ].

Many other therapies to ameliorate burn-induced hypermetabolism have been investigated. Environmental management with the warming of patients’ rooms and occlusive wound dressings attenuate the hypermetabolic response because burn patients have lost their skin barrier and therefore need to produce more heat to maintain thermal neutrality. Early wound excision and grafting have led to improvements in mortality, decreased exudative protein loss, lower risk of burn wound infection, and decreased muscle catabolism [ 19 , 23 ]. This may be due to a decrease in the levels of circulating inflammatory cytokines such as interleukin (IL)-6, IL-8, C3 complement, and tumor necrosis factor (TNF)-α [ 24 ].

Several proven pharmacologic methods can be used to decrease the hypermetabolic response to burn. Beta-adrenergic receptor blockade, usually with propranolol, lowers the heart rate and metabolic rate in patients with severe burns [ 25 – 27 ]. Recently, propranolol treatment for 1-year postburn was shown to improve peripheral lean body mass accumulation [ 28 ]. Oxandrolone, a synthetic androgen, has been shown to blunt hypermetabolism, improve bone mineral content and density, and increase the accretion of lean body mass in children with severe burn [ 29 – 32 ]. Recombinant human growth hormone (rHGH) has been found to reduce hypermetabolism and improve lean body mass accretion after burn, but its use has been limited because of two multicenter trials showing that growth hormone therapy increased mortality in critically ill adults [ 33 – 35 ]. More research is needed regarding the efficacy and safety of rHGH use in burn patients.

Timing of nutritional support

Time to treatment, including time to nutrition, is an important factor for patient outcome after severe burn. Substantial intestinal mucosal damage and increased bacterial translocation occur after burn and result in decreased absorption of nutrients [ 36 ]. Because of this, nutritional support should ideally be initiated within 24 h of injury via an enteral route [ 2 , 19 ]. In animal models, early enteral feeding has been shown to significantly attenuate the hypermetabolic response after severe burn. Mochizuki et al. demonstrated that guinea pigs who were continuously fed enterally starting at 2 h after burn had a significant decrease in metabolic rate at 2 weeks after burn compared to animals whose nutrition was initiated 3 days after burn [ 17 ]. This improvement of the hypermetabolic response has not borne out in human studies; however, early enteral nutrition (EN) has been shown to decrease circulating catecholamines, cortisol, and glucagon and preserve intestinal mucosal integrity, motility, and blood flow [ 18 , 37 – 40 ]. Early enteral feeding in humans has also shown to result in improved muscle mass maintenance, improved wound healing, decreased risk of Curling ulcer formation, and shorter intensive care unit stay [ 21 , 22 ]. Nutrition, both parenteral and enteral, is almost always administered in a continuous fashion. For parenteral nutrition (PN), this is done for logistical reasons, but reasons for continuous feeding are less clear for EN. At the start, enteral feeding is initiated in a continuous and low volume manner with slow titration to the goal volume to insure that the patient can tolerate this regimen. A continuous schedule is usually continued even when the patient is having no issues with tolerance. Continuous enteral feeding is likely a holdover from parenteral schedules and no data have shown the superiority of either schedule, but the data are limited [ 41 ]. Normal physiology functions with intermittent feeding usually during daytime hours, and further research is needed to determine if there might be a benefit to intermittent feeding after burn.

Caloric requirements

The primary goal of nutritional support in burn patients is to fulfill the increased caloric requirements caused by the hypermetabolic state while avoiding overfeeding. Numerous formulas to estimate the caloric needs of burn victims have been developed and used throughout the years [ 42 ]. One of the earliest examples is the Curreri formula [ 43 ]. It was proposed in 1972 and created by studying 9 patients and computing backwards to approximate the calories that would have been needed to compensate for the patients’ weight loss. The Curreri formula and many other older formulas overestimate current metabolic requirements, and more sophisticated formulas with different variables have been proposed (Table  1 ) [ 44 ]. One study of 46 different formulas for predicting caloric needs in burn patients found that none of them correlated well with the measured energy expenditure in 24 patients [ 1 ]. Energy expenditure does fluctuate after burn, and fixed formulas often lead to underfeeding during periods of highest energy utilization and to overfeeding late in the treatment course.

Indirect calorimetry (IC) is the current gold standard for the measurement of energy expenditure, but it is not practical to perform on a routine basis. IC machines measure the volume of expired gas and the inhaled and exhaled concentrations of oxygen and carbon dioxide via tight-fitting face masks or ventilators, allowing for the calculation of oxygen consumption (VO 2 ) and carbon dioxide production (VCO 2 ), and therefore metabolic rate [ 45 ]. IC can also detect underfeeding or overfeeding by calculation of the respiratory quotient (RQ), which is the ratio of carbon dioxide produced to oxygen consumed (VCO 2 /VO 2 ) [ 42 ]. This ratio is affected by the body’s metabolism of specific substrates. In unstressed starvation, fat is utilized as a major energy source which produces an RQ of <0.7. The normal metabolism of mixed substrates yields an RQ of around 0.75–0.90. Overfeeding is typified by the synthesis of fat from carbohydrate resulting in an RQ of >1.0. This explains one feared complication of overfeeding: difficultly weaning from ventilatory support [ 46 ]. Despite this concern, one study found that high-carbohydrate diets in a group of pediatric burn patients led to decreased muscle wasting and did not result in RQs over 1.05 or any respiratory complications [ 47 ].

The metabolic process involves the creation and degradation of many products necessary for biological processes. Metabolism of three macronutrients—carbohydrates, proteins, and lipids—provide energy via different pathways (Fig.  2 ).

Metabolism of protein, carbohydrates, and lipids

Carbohydrates

Carbohydrates are the favored energy source for burn patients as high-carbohydrate diets promote wound healing and impart a protein-sparing effect. A randomized study of 14 severely burned children found that those receiving a high-carbohydrate diet (in comparison to a high-fat diet) had significantly less muscle protein degradation [ 48 ]. This makes carbohydrates an extremely important part of the burn patient’s diet; however, there is a maximum rate at which glucose can be oxidized and used in severely burned patients (7 g/kg/day) [ 49 , 50 ]. This rate can be less than the caloric amount needed to prevent lean body mass loss, meaning severely burned patients may have greater glucose needs than can be safely given. If glucose is given in excess of what can be utilized, it leads to hyperglycemia, the conversion of glucose to fat, glucosuria, dehydration, and respiratory problems [ 51 ].

The hormonal environment of stress and acute injury causes some level of insulin resistance, and many patients benefit from supplemental insulin to maintain satisfactory blood sugars. Insulin therapy also promotes muscle protein synthesis and wound healing [ 52 ]. Studies have found that severely burned patients who received insulin infusions, in conjunction with a high-carbohydrate, high-protein diet, have improved donor site healing, lean body mass, bone mineral density, and decreased length of stay [ 53 , 54 ]. Hypoglycemia is a serious side effect of insulin therapy, and patients must be monitored closely to avoid this complication.

Fat is a required nutrient to prevent essential fatty acid deficiency, but it is recommended only in limited amounts [ 13 ]. After burn, lipolysis is suppressed and the utilization of lipids for energy is decreased. The increased beta-oxidation of fat provides fuel during the hypermetabolic state; however, only 30% of the free fatty acids are degraded and the rest go through reesterification and accumulate in the liver. Additionally, multiple studies suggest that increased fat intake adversely affects immune function [ 55 , 56 ]. Because of these effects, many authorities recommend very low-fat diets (<15% of total calories) in burn patients where no more than 15% of total calories come from lipids. Multiple low-fat enteral formulas have been created for this purpose, and for patients receiving short-term (<10 days) PN, many clinicians forego lipid emulsions.

In addition to the amount of fat, the composition of administered fat must be considered. The most commonly used formulas contain omega-6 fatty acids such as linoleic acid, which are processed via the synthesis of arachidonic acid, a precursor of proinflammatory cytokines (e.g., prostaglandin E 2 ). Lipids that contain a high percentage of omega-3 fatty acids are metabolized without promoting proinflammatory molecules and have been linked to enhanced immune response, reduced hyperglycemia, and improved outcomes [ 57 , 58 ]. Because of this, omega-3 fatty acids are a major component of “immune-enhancing diets.” Most enteral formulas have an omega 6:3 ratio between 2.5:1 and 6:1 while the immune-enhancing diets have an omega 6:3 ratio closer to 1:1. The ideal composition and amount of fat in nutritional support for burn patients remains a topic of controversy and warrants further investigation.

Proteolysis is greatly increased after severe burn and can exceed a half pound of skeletal muscle daily [ 59 ]. Protein supplementation is needed to meet ongoing demands and supply substrate for wound healing, immune function, and to minimize the loss of lean body mass. Protein is used as an energy source when calories are limited; however, the opposite is not true. Giving excess calories will not lead to increased protein synthesis or retention, but rather lead to overfeeding.

Supplying supranormal doses of protein does not reduce the catabolism of endogenous protein stores, but it does facilitate protein synthesis and reduces negative nitrogen balance [ 60 ]. Currently, protein requirements are estimated as 1.5–2.0 g/kg/day for burned adults and 2.5–4.0 g/kg/day for burned children. Non-protein calorie to nitrogen ratio should be maintained between 150:1 for smaller burns and 100:1 for larger burns [ 61 ]. Even at these high rates of replacement, most burn patients will experience some loss of muscle protein due to the hormonal and proinflammatory response to burn injury.

Several amino acids are important and play unique roles in recovery after burn. Skeletal muscle and organ efflux of glutamine, alanine, and arginine are increased after burn. These amino acids are important for transport and help supply energy to the liver and healing wounds [ 62 ]. Glutamine directly provides fuel for lymphocytes and enterocytes and is essential for maintaining small bowel integrity and preserving gut-associated immune function [ 63 , 64 ]. Glutamine also provides some level of cellular protection after stress, as it increases the production of heat shock proteins and it is a precursor of glutathione, a critical antioxidant [ 64 – 66 ]. Glutamine is rapidly exhausted from muscle and serum after burn injury, and administration of 25 g/kg/day of glutamine has been found to reduce mortality and length of hospitalization in burn patients [ 67 , 68 ]. Arginine is another important amino acid because it stimulates T lymphocytes, augments natural killer cell performance, and accelerates nitric oxide synthesis, which improves resistance to infection [ 69 , 70 ]. The supplementation of arginine in burn patients has led to improvement in wound healing and immune responsiveness [ 70 – 72 ]. Despite some promising results in the burn population, data from critically ill nonburn patients suggest that arginine could potentially be harmful [ 73 ]. The current data is insufficient to definitively recommend its use, and further study is warranted.

Vitamins and trace elements

The metabolism of numerous “micronutrients” (vitamins and trace elements) is beneficial after burn as they are important in immunity and wound healing. Severe burn leads to an intense oxidative stress, which combined with the substantial inflammatory response, adds to the depletion of the endogenous antioxidant defenses, which are highly dependent on micronutrients [ 74 , 75 ]. Decreased levels of vitamins A, C, and D and Fe, Cu, Se, and Zn have been found to negatively impact wound healing and skeletal and immune function [ 76 – 78 ]. Vitamin A decreases time of wound healing via increased epithelial growth, and vitamin C aids collagen creation and cross-linking [ 79 ]. Vitamin D contributes to bone density and is deficient after burn, but its exact role and optimal dose after severe burn remains unclear. Pediatric burn patients can suffer significant dysfunction of their calcium and vitamin D homeostasis for a number of reasons. Children with severe burn have increased bone resorption, osteoblast apoptosis, and urinary calcium wasting. Additionally, burned skin is not able to manufacture normal quantities of vitamin D3 leading to further derangements in calcium and vitamin D levels. A study of pediatric burn patients found that supplementation with a multivitamin containing 400 IU of vitamin D2 did not correct vitamin D insufficiency [ 80 – 82 ]. More investigation into therapies to combat calcium and vitamin D deficiency is needed. The trace elements Fe, Cu, Se, and Zn are important for cellular and humoral immunity, but they are lost in large quantities with the exudative burn wound losses [ 77 ]. Zn is critical for wound healing, lymphocyte function, DNA replication, and protein synthesis [ 83 ]. Fe acts as a cofactor for oxygen-carrying proteins, and Se boosts cell-mediated immunity [ 75 , 84 ]. Cu is crucial for wound healing and collagen synthesis, and Cu deficiency has been implicated in arrhythmias, decreased immunity, and worse outcomes after burn [ 85 ]. Replacement of these micronutrients has been shown to improve the morbidity of severely burned patients (Table  2 ) [ 2 , 75 , 86 , 87 ].

Routes of nutrition: parenteral vs. enteral

PN was routinely used for burn patients in the 1960s and 1970s, but it has been almost completely replaced by EN [ 88 ]. Studies found that PN, alone or in conjunction with EN, is associated with overfeeding, liver dysfunction, decreased immune response, and three-fold increased mortality [ 89 , 90 ]. PN also appears to increase the secretion of proinflammatory mediators, including TNF, and also can aggravate fatty infiltration of the liver [ 91 , 92 ]. In addition to these issues, PN has more mechanical and infectious complications of catheters, and PN solutions are significantly more expensive than EN formulas.

EN, in addition to being a safe and cost effective feeding route, has been found to have many advantages. The presence of nutrients within the lumen of the bowel promotes function of the intestinal cells, preserves mucosal architecture and function, stimulates blood supply, decreases bacterial translocation, and improves gut-associated immune function [ 36 , 39 ]. EN decreases hyperglycemia and hyperosmolarity as it has a “first-pass” hepatic delivery of nutrients [ 17 ]. For all of these reasons, EN is the route of choice for severely burned patients. EN can be administered as either gastric or post-pyloric feedings, and both are widely used. Gastric feeding has the advantages of larger diameter tubes, which have less clogging and the ability to give bolus feeds; however, the stomach often develops ileus in the postburn state. Smaller post-pyloric tubes are more prone to clogging and malposition, but they are often more comfortable and post-pyloric feedings can be safely continued even during surgical procedures to sustain caloric goals without an increased risk of aspiration [ 93 ]. Despite the strong preference to give nutritional support primarily via the gastrointestinal tract, PN can be used in burned patients in whom EN is contraindicated. Further research is warranted regarding if parenteral supplementation of specific dietary components, such as amino acids alone, would be beneficial. PN and EN are usually given in a continuous fashion.

The earliest formulas for burn patients consisted of milk and eggs, and although these simple mixtures were relatively successful at providing adequate nutrition, they were very high in fat. Numerous commercially prepared enteral formulas have been developed since that time, all with differing amounts of carbohydrates, protein, fats, and micronutrients (Table  3 ). Glucose is the preferred energy source for burn patients and they should therefore be administered a high-carbohydrate diet [ 47 , 94 ]. Parenteral formulas usually consist of 25% dextrose, 5% crystalline amino acids, and maintenance electrolytes. This is often supplemented with infusions of 250 mL of 20% lipid emulsions three times a week to meet essential fatty acid needs [ 95 , 96 ].

Immune-enhancing diets, or immunonutrition, are nutritional formulas that have been enriched with micronutrients in an effort to improve immune function and wound healing. These formulas gained attention after Gottschlich et al. found that severely burned children given a tube feeding formula containing omega-3 fatty acid, arginine, histidine, and vitamins A and C had significantly fewer wound infections, shorter length of stay, and trended toward improved survival compared to children fed commercially available formulas [ 97 ]. This led to the commercial production of similar immune-enhancing diets. Subsequent study of these formulas has shown that they lead to an improvement in neutrophil recruitment, respiratory gas exchange, cardiopulmonary function, mechanical ventilation days, and length of stay in some nonburn populations [ 98 , 99 ]. Studies in patients with sepsis and pneumonia, however, suggest immune-enhancing diets could have a harmful effect [ 73 , 98 ]. Little research exists regarding immune-enhancing diets in the burn population. A small study by Saffle et al. found no difference in major outcome variables between the immune-enhancing diet, Impact (Nestle HealthCare, Florham Park, NJ), and a high-protein stress formula, Replete (Nestle HealthCare) [ 100 ]. It has been theorized that because of the high volume of feedings given to burn patients, they may receive a satisfactory dose of most immune-enhancing nutrients with the use of conventional diets. A multitude of formulas and numerous methods for calculating nutritional needs are used successfully in the burn population, which suggests that no formula or calculation is perfect, but most are adequate to prevent nutritional complications.

The study of nutrition and metabolism in burn patients is difficult to perform in an exacting and precise method because both the pathophysiology of burn injury and the treatment modalities during the course of burn care are very complex. The effects of differing compositions of nutritional support can easily be confounded by variations in treatment modalities and the complicated pathophysiology of individual burn patients at different stages of their treatment course. A single burn unit takes a very long time to gather data from enough patients which could introduce confounders as other treatment methods advance and change. Multi-institutional trials are also difficult, and any difference in treatment protocols among institutions could overshadow effects of differing nutritional support. A wide range of clinical trials on different nutritional regimens are still being carried out and have not reached convincing consensus on optimal nutrition for burn patients. Physiological/biochemical markers need to be developed or used to assess the potential benefits of these nutrients in parallel to the ongoing evidence-based clinical trials.

The rate of obesity has rapidly grown over the past 30 years in both the USA and worldwide [ 101 ]. Approximately two thirds of the US population are overweight, and one third meet the BMI criteria for obese [ 102 ]. In the general population, obesity is clearly linked with multiple health problems including diabetes, cardiovascular disease, arthritis, and morbidity [ 103 ]. Strangely, overweight and moderately obese patients in surgical and medical intensive care units have been found to have a reduced mortality compared to normal weight patents, despite a higher rate of infections and longer length of stay [ 104 , 105 ]. Data in the burn population are more limited. A study of the National Burn Repository found a higher mortality for patients listed as obese, but the study was limited due to nonstandard data fields in the database, and the term “obese” was not clearly defined [ 106 ]. Two small pediatric studies demonstrated longer hospital stays and a greater need for ventilatory support in obese burned children [ 107 , 108 ].

Obesity has significant physiologic effects, and fat plays an active role in metabolic regulation. Obesity is associated with an elevated secretion of proinflammatory cytokines, including IL-6, TNF-alpha, and C-reactive protein, and obesity is posited to be a state of chronic inflammation [ 109 , 110 ]. After burn, obese patients may respond with amplified inflammation, increased hypermetabolism, brisker and more severe muscle wasting, and severe insulin resistance [ 111 ]. Obese patients also have decreased bioavailability of vitamin D3 compared to non-obese patients which can potentially worsen vitamin D and calcium deficiency after burn in this population [ 80 ].

Obesity also makes initial nutritional assessment difficult as obese patients can still be malnourished, and using actual body weight in predictive formulas overestimates energy needs, while ideal body weight underestimates the needs. A few formulas specifically for obese patients have been created but have not been validated. Some clinicians endorse the use of hypocaloric feeding which consists of low-calorie, high-protein diets with the goal of maintaining lean body mass while promoting weight loss and glycemic control [ 112 ]. A few small trials in nonburn patients found that patients on a hypocaloric diet had reduced mortality, ventilator dependence, and length of stay [ 113 , 114 ]. Data remain very limited in nonburn patients and nonexistent in the burn population, and more studies will need to be done before this can be recommended.

Monitoring of nutritional support

It is challenging to objectively assess the success of nutritional support of a burn patient, as the true endpoint of therapy is global and cannot be measured by one variable. The overall goal of therapy is to reestablish normal body composition and metabolic equilibrium, and commonly measured variables include body weight, nitrogen balance, imaging of lean body mass, and measurement of serum proteins. Functional measures such as exercise tolerance have also been proposed as a possible metric.

Body weight is a tempting measure of nutritional status as it is easy to obtain and is useful in the general population; however, it can be very misleading in burn patients. The initial fluid resuscitation after severe burn routinely adds 10–20 kg or more of body weight, and although this will eventually lead to diuresis, the time course is unpredictable [ 115 ]. Additional fluid shifts occur with infections, ventilator support, and hypoproteinemia, making body weight a very unreliable gauge of nutrition in this population. Patients can have increased total body water for weeks after the burn, which can mask the loss of lean body mass that has certainly occurred [ 116 ]. A study of severely burned children found that increasing caloric intake to maintain weight resulted in increased fat mass instead of improved lean body mass [ 48 ]. Long-term trends are valuable, and weight should be monitored, especially during the rehabilitation phase.

Providing adequate protein intake is an extremely important part of nutritional support after burn. Nitrogen is a fundamental component of amino acids, and as such, the measurement of nitrogen inputs and losses can be used to study protein metabolism. A positive nitrogen balance is associated with periods of growth as it represents an increase in the total body amount of protein, while negative nitrogen balance occurs with burns, trauma, and periods of fasting. Measurement requires accurate urine collection for determination of urea nitrogen (UUN) as well as documentation of dietary nitrogen intake [ 117 ]. Nitrogen balance for burn patients can be approximated with the following formula:

Errors in the calculation can come from the two constants. To approximate total urinary nitrogen, 4 g/dL is added to UUN, but total urinary nitrogen may surpass this value in burn patients, leading to an underestimation of nitrogen loss [ 118 , 119 ]. To account for substantial loss of protein-rich exudates from burn wounds, estimated total urinary nitrogen is multiplied by 1.25, which can similarly underestimate nitrogen losses.

Measurement of serum proteins such as albumin and prealbumin can be utilized to assess nutritional status, but they also have limitations. Metabolic pathways are shifted away from maintenance of these proteins after burn injury, and serum albumin levels are depressed both acutely and chronically, even with successful nutrition, making it a poor marker [ 120 ]. Prealbumin has a short half-life of 2 days which theoretically makes it more responsive to nutritional changes. In reality, the level of prealbumin falls quickly after burn and recovers slowly and may not correlate well with ongoing nutritional status [ 121 ]. Protein markers, similar to body weight, should be interpreted in context with the patient’s clinical status and with the overall trend in mind.

A few imaging techniques are now available for nutritional monitoring, although due to availability and cost they are typically used in research only. Bioimpedance analysis is a method to calculate total body water and the body’s fat-free cell mass by measuring the body’s resistance to the passage of electrical currents, although it is unknown how the fluid shifts after burn affects this measurement. Another imaging option is dual x-ray absorptiometry (DEXA) scanning, which can measure bone density and lean body mass.

Graves et al. surveyed 65 burn centers in 2007 regarding their nutritional monitoring practices, and the most commonly used parameters were prealbumin (86% of centers), body weight (75%), calorie count (69%), serum albumin (45.8%), nitrogen balance (54%), and transferrin (16%) [ 122 ]. No individual method is universally reliable or applicable for the nutritional monitoring of burn patients, and the overall clinical picture must be incorporated into the assessment.

Overfeeding

The estimation of the nutritional needs of burn patients can be very difficult, and aggressive nutrition in the early post-injury stage can lead to inadvertent overfeeding as the metabolic rate slows and intestinal absorption improves. Overfeeding carries numerous complications, including difficulty weaning from ventilatory support, fatty liver, azotemia, and hyperglycemia. Overfeeding of carbohydrates leads to fat synthesis, increased carbon dioxide, and an increase in the RQ, which worsens respiratory status and makes liberation from the ventilator more challenging [ 44 ]. After burn, the hypermetabolic response leads to the mobilization of all available substrates, and this marked increase of peripheral lipolysis can lead to the development of a fatty liver. Overfeeding, via the parenteral or enteral route, can exacerbate the deposition of fat in the liver parenchyma, and fatty liver has been associated with immune dysfunction and increased mortality [ 92 ]. Azotemia can occur due to the large amounts of protein administered to burn patients. This is important as the massive fluid shifts after burn can cause a prerenal kidney injury, and increased blood urea nitrogen can aggravate the stress already placed on the kidney. Patients with azotemia which does not respond to hydration may need a reduced amount of protein in their nutrition and need to be closely monitored for signs of renal failure. Nutritional support should be continued in patients with renal failure, but blood chemistries should be checked regularly as metabolic derangements are common and must be addressed.

The predictive formulas of nutritional needs should be used as guidelines, and patients’ energy requirements should be regularly reassessed. As the acute hypermetabolic phase tapers, the more standard equations and injury/activity factors can be used to avoid overfeeding. Factors such as the changing amount of open wound and physical/occupational therapy activity should be taken into account when estimating nutritional needs.

Nutrition after discharge

It is important that patients continue to receive adequate nutrition after discharge from the hospital, but data on the optimal diet after the acute postburn phase are virtually nonexistent. Because the hypermetabolic state can persist for over a year after burn injury, increased caloric intake with a high protein component is usually recommended for about a year after discharge. Resistance exercise is also recommended to combat continued loss of muscle mass. Patients should regularly weigh themselves to ensure they are maintaining their weight as instructed by the physician and dietician. Oxandrolone is often continued in the outpatient setting, but no data exist regarding the optimum duration of therapy and further study is needed. Nutritional assessments should be a consistent component of outpatient follow-up for burn patients.

Conclusions

The delivery of nutritional support is a vital element of burn care, and the main goal is simply to avoid nutritional complications. Effective assessment and management can optimize wound healing and decrease complications and mortality. EN with high-carbohydrate formulas is beneficial, although nutritional support must be individualized, monitored, and adjusted throughout recovery. Accurate nutritional endpoints and goals need to be established and validated before the optimal nutritional regimen can be determined. Basic science analysis of the metabolic changes after burn must be coupled with randomized prospective clinical trials to ascertain the ideal nutritional support for the burn patient.

Abbreviations

Adenosine triphosphate

Enteral nutrition

Indirect calorimetry

Interleukin

Parenteral nutrition

Resting energy expenditure

Recombinant human growth hormone

Respiratory quotient

Total body surface area

Tumor necrosis factor

Uncoupling protein 1

Urea nitrogen

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Saffle JR, Graves C, Cochran A. Nutritional support of the burned patient. In: Herndon DN, editor. Total burn care. London: W.B. Saunders; 2012. p. 333–53. e335.

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This work was generously supported by the nonprofit organizations Sons of the Flag and Carry the Load.

We thank Dave Primm for his assistance and comments on this manuscript.

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AC was the major contributor in writing the manuscript. TM and JI performed the literature review and were contributors in writing the manuscript. SW made major contributions to defining the scope of the review, literature review, and writing and editing the manuscript. All authors read and approved the final manuscript.

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Audra Clark, Jonathan Imran, Tarik Madni & Steven E. Wolf

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Clark, A., Imran, J., Madni, T. et al. Nutrition and metabolism in burn patients. Burn Trauma 5 , 11 (2017). https://doi.org/10.1186/s41038-017-0076-x

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Burn - Case Summary

2. Symptoms of shock include increased heart rate, increased respiration rate, pale cool skin, and possibly falling blood pressure. While a first or second-degree burn is painful, third-degree burns destroy sensory neurons and are therefore without pain. Coughing or difficulty breathing may indicate damage to the lungs from smoke inhalation. Core body temperatures are typically high because the body's thermostat in the hypothalamus is reset.

3. The amount of body surface area burned can be estimated using the rule of nines. The severity of the burn is assessed by redness only (first degree), blistering (second degree), or marble-white to mahogany or dry charred skin (third degree).

More information about the extent of internal damage from the burn is assessed using a CBC, Chemistry panel, Urinalysis, Carboxyhemoglobin, and Chest X-ray. In this patient, an elevated WBC count with an elevation of neutrophils indicated widespread inflammation from the burn. An elevated Hct was due to loss of plasma and fluids. Glucose levels are slightly elevated from the patient's stress response. Extremely elevated levels of creatine kinase indicate muscle breakdown. High levels of BUN indicate kidney damage. Total proteins levels are low from a loss of blood plasma and proteins.

The Chest X-ray indicated no lung damage. Low levels of carboxyhemoglobin along with the chest x-ray results, indicated there was little smoke inhalation in this burn.

4. Shock is treated by laying the patient down and raising and supporting the legs. The patient should be kept warm and the patient's airway and breathing should be constantly monitored. CPR should be performed if the patient is not breathing.

Major concerns with a burn patient are the loss of fluids, infection (from loss of the protective barrier of the skin), and lung damage from smoke inhalation. In this patient, edema in the face and neck was obstructing the airway. Mechanical ventilation was used to open the airway and breathe for Anna until the swelling subsides. IV fluids were used to treat the fluid loss. Urinary output was carefully monitored so that enough fluids are given to replace fluid loss. Silver, antimicrobial dressings guard against infection until the patient is stable enough for surgery. Skin debridement prepares the area for skin grafting which will replace the lost skin barrier.

A nasogastric tube is used for enteral feedings. Caloric intake must be greatly increased (as much as 5000 calories/day) to counteract the high metabolic rate induced by a burn).

5. There are approximately 450,000 burn injuries that receive medical treatment each year in the United States (American Burn Association, 2013). The amount of deaths from smoke inhalation is reported as 3,400/year with 40,000 hospitalizations each year from burn-related injuries.

The prognosis of a burn patient depends on the extent and severity of the burn. The very young and the very old also have a more difficult time recovering from a major burn. First and some second-degree burns may heal within days to weeks. Deep second-degree burn and third-degree burns take weeks to months to heal and usually cause scarring. Most of these burns require skin grafts. A burn that involves more than 90% of the total body surface (more than 60% in an older person), is usually fatal.

6. Burn prevention and fire safety tips are discussed in this link. Most of the suggestions are common sense. In Anna's case, if she had realized the proper way to put out a grease fire, she could have prevented the explosion. When the bacon grease started to smoke, she should have removed the pan from the stove. The depth of the frying pan should have been double the amount of grease. If she had 1 inch of grease, the frying pan should have been at least 2 inches deep. She could have used a screen to cover the pan to reduce the chance of splatters. Water should never be used to extinguish a grease fire. Anna could have covered the pan with a metal lid, used baking soda to extinguish the flame, or used a Class B dry chemical fire extinguisher. A fire extinguisher will contaminate the kitchen but it's better than burning up the house!

Case Report: Burns

Mark J. Johnston, RN BSN Manager, Burn Program

Case: 15 Month old with a 19% TBSA burn

HPI: The patient is a 15 month old that sustained a 19%TBSA burn that was the result of hot water. The parents reported that the patient fell into a bathtub full of hot water at approximately 5am. The father awoke to him crying and pulled him out of the tub and ran cold water over the burn areas which were bilateral lower extremities and his lower torso and abdomen. The burns were initially described as not too bad so the father put him in bed and they fell back asleep. Later that morning they awoke and the patient had developed blisters so they presented to a local hospital. The regional Burn Center was consulted. The referring hospital described a ~30%TBSA burn. A left external jugular line was established and a foley catheter was placed. IVF were started at 75cc/hr in addition to a 250cc bolus.

Burn ICU: The patient arrived as a direct admit to the Burn Center. He had received 337.5cc of LR prior to arrival and had 75cc of urine output over 4 hours prior to the admission. 10 point ROS was negative, immunizations were up to date, he did not have any allergies and did not take any medications regularly. Vital signs were: BP 84/62, HR 159, RR 28, SpO2 99% and temp 36.2. His burns were dressed in silver sulfadiazine, he was given fentanyl and midazolam for his dressing and IV fluids continued at 75cc/hr. He was started on our Nurse Driven Resuscitation Protocol. A social work consult was ordered due to the nature of the injuries not being consistent with the mechanism of injury. The patient maintained an adequate amount of urine and so IV fluids were titrated downward and eventually discontinued. The patient was interactive and tolerating a regular pediatric diet. On post burn day (PBD) #1, the burns were dressed with a long term silver dressing. The patient spiked a temperature to 103.3. Child Protection and Law Enforcement were in contact with the patient�s mother as the father had been arrested for suspicion of causing the injuries to the patient.

On PBD#3 the patient had low urine output and PO intake was noted to be poor. A PIV was not able to be established after multiple attempts. Urine output became difficult to measure as it was frequently mixed with stool in the patient�s diaper. The patient was taken to the operating room so that an IJ line could be placed as well as a NJ enteral feeding tube and foley catheter. The patient was left intubated. Blood and urine cultures were sent. The patient was given albumin. He was noted to be hypothermic. ABG showed metabolic acidosis, he was tachycardic with an adequate blood pressure, WBC was 2.8 with zero neutrophils. Venous saturation was high as was his lactate. Due to the septic picture, the patient was started on antibiotics.

On PBD#4 the patient was hypotensive that intermittently improved with colloid infusion. He again developed a fever with marked metabolic acidosis. He developed ventilator dyssynchrony so he was pharmacologically paralyzed. He developed significant edema due to the necessary fluid resuscitation that was initially treated with furosemide. Blood and urine cultures were negative to date.

On PBD#5 the patient was started on a dexmedetomidine in hopes that the midazolam infusion could be discontinued. Due to ventilator dyssynchrony, elevated ventilator peak pressures, oliguria and a tense abdomen, he was taken to the operating room and underwent a decompressive laparotomy and placement of an abdominal wall silo. Postoperatively his diuretic dosing was increased and he was switched to a furosemide infusion and chlorothiazide due to poor urine output.

On PBD#6 the furosemide was switched to bumetanide. Fortunately, after the abdominal decompression, his renal function improved, urine output improved, and creatinine normalized. He remained on continuous dexmedetomidine, fentanyl, and midazolam infusions while intubated. He had good pain control and sedation.

Over the course of the subsequent days, the patient underwent three abdominal washouts and had the abdominal wound closed nine days after the laparotomy. He underwent tangential excision and cadaver grafting on PBD#14 and split thickness skin grafting on PBD#24. He was discharged on PBD#37.

Post Discharge: The patient was evaluated in the Burn Clinic 3 weeks after his discharge and he had 100% graft take and no other concerns. The patient was followed at regular intervals in the Burn Clinic and the patient had no other issues of concern.

Topic Review: Abdominal Compartment Syndrome in Pediatric Burn Resuscitation Burn patients receive a larger amount of fluids in the first 24 h than any other trauma patients because of the pathophysiological mechanisms occurring in the injury. Burn shock is a combination of hypovolemic shock and cell shock, characterized by specific microvascular and hemodynamic changes. In addition to the local lesion, the burn stimulates the release of inflammatory mediators that induce an intense systemic inflammatory response, producing an increase in vascular permeability in both the healthy and the affected tissue. The increased permeability provokes an outpouring of fluids from the intravascular space to the interstitial space, giving rise to edema, hypovolemia, and hemoconcentration. The amount of inhalation injury also has an effect on the clinical course, fluid requirements, and the patient's prognosis. The main objective of fluid administration in thermal trauma is to preserve and restore tissue perfusion and prevent ischemia, but resuscitation is complicated by the edema and transvascular displacement of fluids characteristic of this condition.1, 2, 3.

Since 1968, when Baxter and Shires developed the Parkland formula, there has been debate on the �perfect� burn resuscitation formula. The advances in hemodynamic monitoring, establishment of the 'goal-directed therapy' concept, and the development of new colloid and crystalloid solutions have put us closer to the �holy grail�. Severe burns have been shown to be a risk factor for developing intra-abdominal hypertension (IAH). Fluid resuscitation practices used in burn management further predispose patients to intra-abdominal hypertension. Many burn units still base their resuscitation practice on a formula created 40 years ago. In 1991, Dries and Waxman(4) had already suggested that resuscitation based only on the urinary output and vital signs might be suboptimal. Goal-directed fluid therapy has been an important concept in initial fluid resuscitation for major burns since this publication. Cardiac output has been considered one of the most important measures to guide volume therapy but few burn centers actually measure cardiac output during resuscitation. In recent years, several articles have reported on volume monitoring and replacement approach for goal-directed fluid resuscitation based on transpulmonary thermodilution (TTD) and arterial pressure wave analysis, which are less invasive .

• RE Barrow, MG Jeschke, DN Herndon Early fluid resuscitation improves outcomes in severely burned children Resuscitation, 45 (2000), pp. 91-96
• CP Artz, JA Moncrief The burn problem CP Artz, JA Moncrief (Eds.), The treatment of burns, W.B. Saunders, Philadelphia (1969), pp. 1-22
• JK Rose, DN Herndon Advances in the treatment of burn patients Burns, 23 (Suppl 1) (1997), pp. S19-S26
• DJ Dries, K Waxman Adequate resuscitation of burn patients may not be measured by urine output and vital signs Crit Care Med, 19 (1991), pp. 327-329

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A Geriatric Patient with Major Burns:Case Report

Gülhane Military Medical Academy, Haydarpa¾a Training Hospital, Plastic and Reconstructive Surgery and Burns Unit, T›bbiye Cad. 34668 Üsküdar, Turkey

E. Ülkür

B. Çeliköz.

As is predictable, mortality and morbidity among geriatric patients are higher in patients with major burns. Decreased radiopulmonary reserves and malnutrition characterized by protein/energy deficiency and ageing of skin are predisposing factors which increase mortality and morbidity. In this study, we present a 90-yr-old patient with 46% total body surface area of 2nd-3rd degree burns. We had to overcome difficulties which can be seen in elderly patients and which succeeded in our treatment.

Comme on peut prévoir, le taux de mortalité et de morbidité chez les patients gériatriques est plus élevé quand ils sont atteints de brûlures importantes. Les réserves radiopoumonaires diminuées et la malnutrition caractérisées par l'insuffisance protéinique/énergétique et le vieillissement de la peau sont des facteurs prédisposant qui augmentent la mortalité et la morbidité. Les Auteurs présentent dans cette étude le cas d'un patient de 90 ans atteint de brûlures de deuxième et troisième degré. Ils ont du surmonter les difficultés que l'on peut avoir chez les patients d'un certain âge, et notre traitement a eu succès.

Introduction

Geriatric patients, usually defined as those older than 65 years of age, comprise approximately 10% of the major burns population. 1 Burns in this age group constitute more serious injuries than in the general population and burns larger than 30% total body surface area (TBSA) cause an extremely high mortality. Co-morbid factors are responsible for this increase in morbidity and mortality. 2 Elderly people have thinner skin, poorer microcirculation, and increased susceptibility to infection 3 , 4 and the rate of burn shock, inhalation injury, pulmonary pathology, septicaemia and renal failure is higher than in younger people. If we compare the number of elderly burn patients over 80 years old with those between 65 and 80 we can see that both these groups are small, but the survival rate, especially in patients with more than 40% TBSA burns, is very low.

In this article we present a 90-yr-old patient who presented challenging difficulties in therapy and care.

A 90-yr-old male patient was admitted to our burns centre after a water heater blast accident at home. Altogether 46% TBSA was burned by flame (2nd-3rd degree). The regions affected were the face, posterior neck, posterosuperior trunk, right anterosuperior trunk, the right lumbar and dorsal side of both upper extremities and both lower extremities (Figs. 1 , 2 , 3 ).

After sedation with 2 mg midazolam i.v. and 50 mg ketamine i.v., the burned areas were scrubbed with distilled water and 7.5% povidine iodine in our washroom. The wounds were closed with 0.5% chlorhexidine acetate and petrolatum gauze. After the initial dressing, the patient was taken to the intensive care unit and fully monitored with central venous, arterial, urinary, and nasogastric catheterization. On day 1, fluid resuscitation was administered according to the Parkland formula, i.e. 4 ml/kg/% TBSA. Crystalloid (Ringer’s lactate) was preferred. The speed of the fluid resuscitation was monitored in relation to urine output and central venous pressure. Dressings were changed daily.

Respiratory support was ensured by postural drainage, respiratory, and Tri-flow exercises, plus cold vapour. Fluid replacement was continued in order to maintain urine output at 0.5-1 cc/kg. Periodically, quantitative and exfoliative wound, urine, and haemocultures were taken. Sefoperazon + Sulbactam 1 g twice daily were initiated owing to high fever on day 3 post-burn. Acinetobacter baumanii was isolated in the haemoculture on day 8. Appropriate antibiotherapy with a sensitive antibiotic was performed. Following the onset of gastroenteritis on day 10, the oral nutritional support solutions were suspended and total parenteral nutrition was commenced. Pseudomonas aeruginosa was isolated in the wound culture on day 17 post-burn, and meropenem and amikacin were given for respectively 32 and 7 days. At the same time silver-coated dressings were applied (Acticoat, Smith and Nephew, USA). 6 , 7 Following subdermal epinephrine infiltration, debridement and grafting were performed in 25% TBSA on post-burn day 19. An intensive physical therapy and exercise programme was initiated after post-operative day 7.

We assessed the patient’s hypotensive and oliguric state on day 26, and therapy with an inotropic agent (dopamine, 2 mg/kg/min) was initiated. After ten days’ therapy this state diminished and inotropic therapy was terminated.

Altogether the patient was hospitalized for 40 days, after which he was discharged as cured (Figs. 4 , 5 , 6 ).

Discussion and conclusion

Although burn treatment has improved during the past few years with the advent of better topical treatments, improved resuscitation, and early burn eschar excision, the prognosis still remains poor for older adult patients, and burn injuries rank forth among the causes of injury-related deaths in the geriatric age group. Mortality in young adults with an 80% TBSA burn is 50%; in persons aged 60-70 yr, a 35% TBSA burn has 50% mortality, and in persons over 70 a 20% TBSA burn will have 50% mortality.

Pre-morbid conditions such as chronic obstructive pulmonary disease (COPD) and coronary artery disease may lead to longer hospital stay, increased ventilation requirements, and elevated complication rates. Agarwal et al. demonstrated that the greater fluid requirements in elderly burn patients led to an increase in congestive heart failure, pulmonary oedema, and pneumonia.

The mortality rate also increases owing to an impaired response to infection and sepsis, as also to decreased ability to tolerate prolonged stress and physiological insult. 11 , 12 , 13 , 14 , 15 , 16 The deficient nutritional state seen in elderly burned patients may also cause impaired wound healing.

Materials used for the purpose of smoking and stoves are reported as frequent sources of injury in older persons, who are most frequently burned during the course of routine daily tasks. In our case the burn was a flame burn.

Physical and physiological differences such as diminished manual dexterity, vision, and hearing, decreased mobility and judgement, and slower reaction times cause injuries in this age group. 18 Because of the diminished reaction time, the severity of burn injuries and the incidence of inhalation injury increase in the geriatric population, and this reduces the size of survivable burn injuries.

Prolonged immobilization and ongoing physiological stress contribute to the significant morbidity related to inhalation injury. Elderly people have decreased pulmonary reserves for gas exchange and lung mechanics and they are prone to pulmonary failure, which is a major cause of death in all burns.

Even when inhalation injury symptoms are totally absent, the early administration of humidified oxygen and nebulization and the use of mycotic agents, position changes, chest physiotherapy, and early ambulation discourage the development of pulmonary problems or attenuate their clinical course in burns caused by flame. In the case we describe, even though there were no signs of inhalation injury, thanks to the early application of respiratory physiotherapy we did not have to treat pulmonary problems.

In elderly people there are several well-recognized risk factors with age, such as chronic illnesses, cardiovascular disease, and decreased pulmonary reserve. The major causes of mortality and morbidity in the elderly following thermal injury are not the burn, but rather alterations due to concomitant disease processes. In this age group, pre-morbid states like COPD and coronary artery disease prolong hospitalization time and increase the need of ventilation support due to the complications.

In elderly people fluid resuscitation is important. These people, like children, are volume-sensitive and may be at risk of hypotensive renal damage. It is advocated that resuscitation fluid should be administered to elderly people with injuries of more than 5% TBSA burns.

Resuscitation solutions should be initiated at a rate of 3-4 ml/kg/% burn and titrated to specific outcome parameters, evaluating any evidence of systemic overload or underhydration. Adequacy of resuscitation should be surmised at 30-50 ml/h urine output, clear mentation, and appropriate blood pressure.

Even after surviving the earliest days of trauma, an oliguric and hypotensive state can be interfaced at any time during therapy, as in our patient, who presented such a condition on day 26 post-burn.

Wound healing is of great concern in older people. There are significant changes in the skin with ageing that are responsible for the greater percentage of deep burns in the elderly, e.g. progressive thinning of the dermis and epidermis. Many factors cause a greater amount of deep burns and a decrease in healing in all phases, such as decreased epidermal turnover and a decrease in skin appendages, vascularity, collagen and matrix, fibroblast, and macrophage levels. 20 , 21 , 22 These unfavourable factors cause a delay in epithelialization, an increase of burn depth, especially in second-degree burn areas, and healing problems at the donor site. In the case reported, areas that did not epithelialize spontaneously were grafted on post-burn day 19.

One such problem, protein energy malnutrition (PEM), has been reported to be present in at least one-third (30-60%) of elderly patients admitted to hospital. PEM has also been found to be three to four times more likely in patients over 65 years of age than in younger patients. 23 , 24 , 25 Malnutrition and involuntary weight loss have been shown to be major risk factors for increased infection, impaired wound healing, and overall disability, the major reason being a loss of body protein and lean body mass. Mortality and morbidity rates seem to be accentuated owing to the addition of a post-burn catabolic state to an existing body protein and energy deficit. 26 , 27 , 28 By giving our patient a high-energy, calorie-rich diet after day 2 post-burn we prevented him from developing a state of protein and energy malnutrition.

Elderly patients need to be aggressively managed to avoid early loss of function or muscle strength, which will be difficult to recover. These patients are capable of restoring muscle strength with resistance exercise and should not be managed conservatively. 29 As with children, providing support and guidance for the family or caretakers is an integral part of care. We performed muscle physiotherapy, beginning with range of motion exercises on post-operative day 10, plus muscle strength exercises.

As a result, despite the high mortality seen in elderly burned patients, it is possible - with early respiration physiotherapy, fluid resuscitation without overload or underhydration, challenge of infection, early surgery, and post-operative physiotherapy - high mortality and morbidity rates can be decreased in this age group.

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Nutrition support in major burn injury: case analysis of dietetic activity, resource use and cost implications

Affiliation.

• 1 Department of Nutrition and Dietetics, Pinderfields General Hospital, Wakefield, UK. [email protected]
• PMID: 18339057
• DOI: 10.1111/j.1365-277X.2008.00860.x

Background: Patients with major burn injury are among the most catabolic and nutritionally vulnerable of all hospital admissions. A considerable amount of dietetic intervention is often required. To date, UK practice has not been described in detail. This study aimed to identify nutritional interventions, resource use and associated costs for a typical patient admitted with major burns.

Methods: A 28-year-old male with 43.5% total body surface area flame injury was selected for study. Dietetic, medical and pharmacy records were reviewed for data regarding nutritional status, interventions and product use. Costs of dietetic staffing, nutrition support products, related ancillary items and hospital food provision were calculated.

Results: The patient required 68 days of nutrition support, including 40 days of nasogastric tube feeding. Seventy per cent of bedside reviews resulted in dietetic intervention. Initiation of nutrition support, substrate use, and frequency of biochemical and weight monitoring were largely in compliance with practice guidelines. Overall cost of nutritional care for the inpatient episode was pound 1377.

Conclusion: Work is now required to assess current nutrition practices across different UK centres and for a range of burn severities, to establish a baseline from which resource and financial requirements can ultimately be developed.

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