Burns MNT 2

Foster Nicholas LLU

Why burns are metabolically unique:

• create most severe _____ of any trauma

• Systemic ____ response

• Massive ____ catabolism

• Severe ____ resistance

• Prolonged ____ alteration

hypermetabolic state, inflammatory, protein, insulin, metabolic

Depth of burn is classified by…

degree

1st degree burn: effects the ___ layer of skin, causing ___, ____

epidermis, slight pain, no blisters

2nd degree burn: effects the ____ and ____ layers of skin, causing more ____ and ___

epidermis, dermis, pain, blisters

3rd degree burn: effects ____ of skin, causing loss of ____, all _____ are destroyed, high risk of ____

full thickness, skin function, dermal elements, infection

4th degree burn: effects _____/___, ____ damage, no ____, usually need ____ to restore nerve function

muscle, bone, nerve, pain, graft

Burn extent is estimated using ____ or ____

TBSA (total body surface area), rule of nines

Mortality risk increases with ___, % _____, and ___ injury- ___ could kill person before they get burned

age, TBSA burned, inhalation, smoke inhalation

Physiologically, burn injury triggers: increased ____ permeability, massive _____ shifts, plasma protein ____, ____ formation, _____. This can rapidly lead to burn ___ without aggressive ___ resuscitation.

capillary, fluid, leakage, edema, hypovolemia, shock, fluid

Simultaneously, inflammatory mediators are released: ____, ___, ___, ____ — sets stage for hypermetabolic response

cytokines, cortisol, glucagon, catecholamines

Burn phases

Ebb, flow, anabolic phase

Ebb phase occurs immediately after injury and lasts ____ days

0-3-5

The ebb phase includes decreased ____, ____, and ____, as well as ___ and ___ risk

cardiac output, oxygen consumption, metabolic rate, hypothermia, shock

What is the priority during ebb phase? ____, not ____

fluid resuscitation, not calories

Burns cause major fluid problems: massive ____ and ____ loss, circulating blood volume would ____ and organs wouldn’t get enough ____, capillaries become ____, leading to ____ into the ____ and ____.

fluid, electrolyte, drop, oxygen, leaky, fluid shifts, interstitial space, edema

Must restore circulating blood volume in ebb phase through ___, usually a ____ solution, given in ____ amounts early on

IV fluids, lactated ringer, large

How to monitor if fluids are adequate: monitor ___ output, make sure ___ is stable, improved ___ and normal ____

urinary, BP, heart rate, mental status

Flow phase is also known as…

hypermetabolic phase

In the flow phase, there is increased ____ output, ____consumption, ____, ______, ______, and _____, as well as severe ____ and accelerated ____.

cardiac, oxygen, resting energy expenditure, body temp, gluconeogenesis, lipolysis, insulin resistance, proteolysis

In the flow phase, resting energy expenditure may rise to ___ of predicted.

150-200%

Flow phase is where _____ becomes critical

aggressive nutrition support

Anabolic phase:

• occurs after ____

• decreased ____

• improved _____

• gradual rebuilding of ____

wound closure, stress hormones, nitrogen balance, lean body mass

Positive nitrogen balance is often not achieved until.

wounds are closed

Nutrition priority of ebb phase:

stabilize fluids

Nutrition priority of flow phase:

high protein, energy support

Nutrition priority of anabolic phase:

rebuild LBM

Hypermetabolism and hormonal response: sympathetic nervous system activation causes increased…

epinephrine and norepinephrine

Increased epinephrine and norepinephrine in hypermetabolism and hormonal response results in….

• ____

• _____

• insulin ____

• stress induced _____

• adrenal cortical stimulation increases ____ such as ____

gluconeogenesis, glycogenolysis, resistance, hyperglycemia, glucocorticoids, cortisol

hypermetabolism is mainly ___ mediated

hormonally

Cortisol increases ____ breakdown, ____, and promotes ____

protein, gluconeogenesis, muscle wasting

Glucagon increases ____ further

blood glucose

Together, cortisol and glucagon accelerate _____, increase mobilization of ___, and increase ____ production

protein catabolism, fat, hepatic glucose

Protein catabolism: BCAA → ____ (becomes substrate for glucose production) → ____, ____ breakdown, negative ____

alanine, glucose, skeletal muscle, nitrogen balance

Lean body mass loss can be…

rapid and severe

Weight changes with burns: initial ___ (___), then _____ (___)

increase, edema, decrease, diuresis

Weight changes may occur from intake such as through ___ or _____

IV fluids, eating/enteral fluids,

Weight changes may occur from output through ___, ___, ___, ___, or insensible losses through ____ and ____

feces, urine, vomiting, blood loss, sweat evaporation, respiration

GI complications: _____ slows ____- for burns, _____ recovers first in ___, then stomach in ____, then ___ in _____

paralytic ileus, peristalsis, small intestine, 24-48 hrs, 48-72, colon, 3-5 days

GI complications: ___- in stomach of patients with extensive ___ burns, ___ lesions, or severe bodily ____

curling ulcer, superficial, intracranial, injury

GI complications include ____ and ____, with often no appetite to eat

anorexia, nausea

Burns can increase resting energy expenditure by up to ____× predicted.

2

Hypermetabolism may increase ____ consumption and ___ production

oxygen, CO2

Risk of overfeeding complications:

overproduction of CO2 → ventilator burden, difficult to wean off ventilator

Clinical risks of hypermetabolism: ___ loss → poor ____ → _____ → prolonged ____

lean body mass, wound healing, immune dysfunction, ventilator dependence

Energy needs for burns are ___ of any trauma

highest

Estimation of energy needs methods:

Curreri formula, Ireton-Jones, Long equation, indirect calorimetry (gold standard), MEEx1.2-1.3

Overfeeding causes ____, increased ____ production, ____, and ____

hyperglycemia, CO2, hepatic steatosis, ventilator burden

Carbs should be ____ of total calories, purpose is to spare ___ and fuel ___

50-60%, protein, wound healing

Max oxidation of carbs: ____

4-7 mg/kg/min

Tight ___ control is required

glucose

Glucose is the preferred ____ source

energy

If overfed: ____ and ___

fat deposition, hyperthermia

Fat should be limited to _____ non-protein kcal

15%

Many hospitals cap at ____ total kcal- high ___ intake can contribute to ____. ___ and ___ fats increase pro-inflammatory mediators

30%, fat, immune suppression, saturated, omega-6

Excess fat may impair…

immunity

Excess fat can reduce activity of ___, impair ___ and ____, and limiting body’s ability to ____

WBC, macrophages, lymphocytes, fight infection

Protein intake for burns: _____ g/kg/day (adults), ____ of total calories

1.5-2.5, 20-25%

The recommended NP kcal:N ratio in burn patients is ____:1

80-100

Extensive protein losses via…

urine and wound exudate

Some formulas recommend ____ g/kg/day

3

Pediatric protein needs: _____ for <1 yr, ____ for >1 hr, higher needs due to ___ and ____

3-4 g/kg, 1.5-3 g/kg, growth, injury

Nitrogen balance: N intake - (___ + ___ + ___)

UUN, fecal, wound losses

Wound N losses increase with…

% open woun

Key concept with N balance: positive N balance usually delayed, occurs after…

wound is closed

Micronutrient repletion or burns: increased ___ stress, ____ losses, and _____ demand. Routine ___ recommended with vitamin ___,___, and ____

oxidative, exudative, collagen synthesis, multivitamin, A, C, zinc

Vitamin A supports ____, enhances ____- ___IU per __ kcal

epithelialization, immune response, 5000, 1000

Vitamin C is an antioxidant required for ____- often ___ per day (___ mg twice daily)

collagen synthesis, 1 g, 500

Zinc is a cofactor in ____, essential for ___- ___ mg zinc sulfate daily

protein synthesis, wound healing, 220

Other nutrients to consider in burns: ___, ___, ___, and ____

selenium, copper, arginine, glutamine

Arginine is important for ____ and _____ stimulation

immune support, anabolic hormone

Glutamine: ___ g/kg actual weight, supports ____, ____, and ____

0.5, GI mucosal integrity, immune cells, N transport

Risks of over-supplementation: ___ excess, ____ deficiency, ________ toxicity, must ____

zinc, → copper, fat-soluble vitamin, individualize

Early enteral nutrition ideally within ____ of injury of burns is recommended

6-12hrs

Benefits of early enteral nutrition: preserves ____, reduces _____, blunts ____ response, decreases ____ rates

gut integrity, bacterial translocation, hypermetabolic, infection

Enteral nutrition formula selection: high ____, possibly immune-modulating ___, ___, ___, and ____ to enhance immunity and healing. Monitor ___ closely

protein, arginine, glutamine, omega 3s, antioxidants, glucose

Arginine: boosts ____ function and enhances ___, improves ___ to injured tissue

t-cell, wound healing, blood flow

Glutamine: primary fuel for ___ and ___ cells, helps maintain ___, prevents ___ from leaking into bloodstream, supports recovery after ____

intestinal, immune, gut integrity, bacteria, stress

Omega 3s help lower excessive ___ and balance ____

inflammation, immune response

Parenteral nutrition is reserved for….

nonfunctional GI tract, severe ileus, and intolerance to EN

Risks of PN:

infection, hyperglycemia, liver dysfunction

Monitoring parenteral nutrition should include ___, ____, ___ balance, ___ status, ____ function, ____ trends

glucose, triglycerides, N, fluid, renal, weight

Respiratory quotient interpretation:

0.7:

0.8-0.85:

1.0:

>1.0:

fat oxidation

mixed substrate

carb oxidation

overfeeding/lipogenesis

When should enteral nutrition ideally begin after severe burn injury?

within 6-12 hrs