Assessment

Nutritional support is recognized as being one of the most significant aspects of care of the burned patient. Burn patients are in an extreme hypermetabolic/hypercatabolic state, so nutritional needs are greatly increased. These increased needs must be met as quickly as possible since wound healing can take place only in an anabolic state.

Traditionally, because of extensive fluid and electrolyte losses through the wound, the first 24 to 48 hours of treatment are devoted to their replacement. Gastrointestinal feeding, or enteral feedings, are usually not begun until patient is resuscitated and gastrointestinal function has returned to normal (usually by the fourth post-burn day). This protocol is followed due to the fear that immediate feeding will cause more complications than delayed feeding. In this particular case, ileus early on along with trauma to upper/lower torso, and head and neck, prevented the use of successful early enteral feeding.

There is controversy among experts as to when feeding of burn patient should begin. Evidence suggests that immediate and early nutrition is helpful in the control of the hypercatabolic and hypermetabolic responses to thermal trauma (1). It has been hypothesized that the lack of enteral feeding early after burn injury can contribute to secondary rises in cortisol, glucagon, and catecholamine levels that contribute to the hypermetabolic response and to multiple organ failure (3,4,5).

Also, failure to keep the gut supplied with nutrients may result in impaired mucosal integrity and translocation of normal gut flora to other regions of the body, leading to systemic infections or sepsis. Many burn units start feeding patients within a few hours of arrival, others within 24-48 hours (you don't have to wait until fluid resuscitation is complete).

Some of the benefits of early enteral feeding are as follows (adapted from ref. 2):

Positive effects on nitrogen balance, serum protein levels, and immunocompetence.
A reduction in the metabolic rate and catabolic processes.
A decrease in adverse effects such as diarrhea or paralytic ileus.
Lack of inhibition of normal absorptive ability of the small intestine early after thermal injury, even in the most critically ill.
Maintain gut mucosal integrity and help prevent translocation of gut flora.
Lower glucagon levels and higher insulin blood levels, enhancing glucose utilization in burned tissues.
More normal levels of urinary catecholamines.
Decreased gluconeogenesis from visceral and muscle protein resulting in a protein-sparing effect.
Earlier occurance of positive nitrogen balance.
Reduced weight loss.

1. Alexander JW: Nutrition and infection. New perspectives for an old problem. Arch. Surg. 121:966, 1986.

2. Chiarelli, A. and Siliprandi, L. Burns. In: Zaloga, G. P., ed. Nutrition in Critical Care. St. Louis, MO: Mosby; 1994: p.587-597.

3. Chiarelli, A., Enzi, G., Casadei, A., et al.: Very early nutrition supplementation in burned patients. Am. J. Clin. Nutr. 51:1035, 1990.

4. Shaw, J.H.F., Wildbore, M., and Wolfe, R.R.: Whole body protein kinetics in severely septic patients. The response to glucose infusion and total parenteral nutrition. Ann. Surg. 294:205-208, 1987.

5. Sologub, V.K., Zaets, T.L., Tarasov, A.V., et al.: Enteral hyperalimentation of burned patients: The possibility of correcting metabolic disorders by the early administration of prolonged high calorie evenly distributed tube feedings. Burns 18:245, 1992.