A prospective observation on nutrition support in adult patients with severe burns

AbstractNutrition therapy is considered an important treatment of burn patients. The aim of the study was to delineate the nutritional support in severe burn patients and to investigate association between nutritional practice and clinical outcomes. Severe burn patients were enrolled (n 100). In 90 % of the cases, the burn injury covered above 70 % of the total body surface area. Mean interval from injury to nutrition start was 2·4 (sd 1·1) d. Sixty-seven patients were initiated with enteral nutrition (EN) with a median time of 1 d from injury to first feed. Twenty-two patients began with parenteral nutrition (PN). During the study, thirty-two patients developed EN intolerance. Patients received an average of about 70 % of prescribed energy and protein. Patients with EN providing <30 % energy had significantly higher 28- d and in-hospital mortality than patients with EN providing more than 30 % of energy. Mortality at 28 d was 11 % and in-hospital mortality was 45 %. Multiple regression analysis demonstrated that EN providing <30 % energy and septic shock were independent risk factors for 28- d prognosis. EN could be initiated early in severe burn patients. Majority patients needed PN supplementation for energy requirement and EN feeding intolerance. Post-pyloric feeding is more efficient than gastric feeding in EN tolerance and energy supplement. It is difficult for severe burn patients to obtain enough feeding, especially in the early stage of the disease. More than 2 weeks of underfeeding is harmful to recovery.

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Effect of high-dose vitamin C therapy on severe burn patients: a nationwide cohort study

Critical Care ◽

10.1186/s13054-019-2693-1 ◽

2019 ◽

Vol 23 (1) ◽

Cited By ~ 3

Author(s):

Mikio Nakajima ◽

Morita Kojiro ◽

Shotaro Aso ◽

Hiroki Matsui ◽

Kiyohide Fushimi ◽

...

Keyword(s):

Propensity Score ◽

Vitamin C ◽

Confidence Interval ◽

Hospital Mortality ◽

Control Group ◽

High Dose ◽

Burn Patients ◽

Severe Burn ◽

Severe Burns ◽

High Dose Vitamin

Abstract Background Vitamin C is a well-documented antioxidant that reduces oxidative stress and fluid infusion in high doses; however, the association between high-dose vitamin C and reduced mortality remains unclear. This study evaluates the effect of high-dose vitamin C in severe burn patients under two varying thresholds. Methods We enrolled adult patients with severe burns (burn index ≥ 15) who were registered in the Japanese Diagnosis Procedure Combination national inpatient database from 2010 to 2016. Propensity score matching was performed between patients who received high-dose vitamin C within 1 day of admission (vitamin C group) and those who did not (control group). High-dose vitamin C was defined as a dosage in excess of 10 g or 24 g within 2 days of admission. The primary outcome was in-hospital mortality. Results Eligible patients (n = 2713) were categorized into the vitamin C group (n = 157) or control group (n = 2556). After 1:4 propensity score matching, we compared 157 and 628 patients who were administered high-dose vitamin C (> 10-g threshold) and controls, respectively. Under this particular threshold, high-dose vitamin C therapy was associated with reduced in-hospital mortality (risk ratio, 0.79; 95% confidence interval, 0.66–0.95; p = 0.006). In contrast, in-hospital mortality did not differ between the control and high-dose vitamin C group under the > 24-g threshold (risk ratio, 0.83; 95% confidence interval, 0.68–1.02; p = 0.068). Conclusions High-dose vitamin C therapy was associated with reduced mortality in patients with severe burns when used under a minimum threshold of 10 g within the first 2 days of admission. While “high-dose” vitamin C therapy lacks a universal definition, the present study reveals that different “high-dose” regimens may yield improved outcomes.

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Sodium variability is associated with increased mortality in severe burn injury

Burns & Trauma ◽

10.1186/s41038-017-0098-4 ◽

2017 ◽

Vol 5 ◽

Cited By ~ 6

Author(s):

Soman Sen ◽

Nam Tran ◽

Brian Chan ◽

Tina L. Palmieri ◽

David G. Greenhalgh ◽

...

Keyword(s):

Serum Sodium ◽

Burn Injury ◽

Total Body Surface Area ◽

Multivariate Logistic Regression Analysis ◽

Median Number ◽

High Plasma ◽

Plasma Sodium ◽

Burn Patients ◽

Severe Burn ◽

Severe Burn Injury

Abstract Background Dysnatremias are associated with increased mortality in critically ill patients. Hypernatremia in burn patients is also associated with poor survival. Based on these findings, we hypothesized that high plasma sodium variability is a marker for increased mortality in severely burn-injured patients. Methods We performed a retrospective review of adult burn patients with a burn injury of 15% total body surface area (TBSA) or greater from 2010 to 2014. All patients included in the study had at least three serum sodium levels checked during admission. We used multivariate logistic regression analysis to determine if hypernatremia, hyponatremia, or sodium variability independently increased the odds ratio (OR) for death. Results Two hundred twelve patients met entry criteria. Mean age and %TBSA for the study was 45 ± 18 years and 32 ± 19%. Twenty-nine patients died for a mortality rate of 14%. Serum sodium was measured 10,310 times overall. The median number of serum sodium measurements per patient was 22. Non-survivors were older (59 ± 19 vs. 42 ± 16 years) and suffered from a more severe burn injury (50 ± 25% vs. 29 ± 16%TBSA). While mean sodium was significantly higher for non-survivors (138 ± 3 milliequivalents/liter (meq/l)) than for survivors (135 ± 2 meq/l), mean sodium levels remained within the laboratory reference range (135 to 145 meq/l) for both groups. Non-survivors had a significantly higher median number of hypernatremic (> 145 meq/l) measurements (2 vs. 0). Coefficient of variation (CV) was significantly higher in non-survivors (2.85 ± 1.1) than survivors (2.0 ± 0.7). Adjusting for TBSA, age, ventilator days, and intensive care unit (ICU) stay, a higher CV of sodium measurements was associated with mortality (OR 5.8 (95% confidence interval (CI) 1.5 to 22)). Additionally, large variation in sodium ranges in the first 10 days of admission may be associated with increased mortality (OR 1.35 (95% CI 1.06 to1.7)). Conclusions Increased variability in plasma sodium may be associated with death in severely burned patients.

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ABDOMINAL COMPARTMENT SYNDROME IN BURN PATIENTS

The Journal of V. N. Karazin Kharkiv National University, Series "Medicine" ◽

10.26565/2313-6693-2018-36-10 ◽

2018 ◽

Keyword(s):

Compartment Syndrome ◽

Abdominal Compartment Syndrome ◽

Fluid Resuscitation ◽

Burn Injury ◽

Abdominal Pressure ◽

Burn Patients ◽

Severe Burn ◽

Severe Burns ◽

Abdominal Hypertension ◽

Abdominal Compartment

Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are consistently associated with morbidity and mortality among the critically ill or injured. Thus, avoiding or potentially treating these conditions may improve patient outcomes. Despite a large number of special publications devoted to this problem, very little attention is paid to the ACS in patients with severe burn injuries. Severe burns have been shown to be a risk factor for developing IAH. Fluid resuscitation practices used in burns management further predispose patients to increase intra-abdominal pressure. The incidence of intraabdominal hypertension in patients with severe thermal injury is, according to different authors, 57.8–82.6 %. The mortality associated with IAH in severe burns is very high once organ dysfunction occurs. The purpose of this work is to collect and analyze the problem of abdominal hypertension in burn patients, as well as to draw conclusions on the prevention of this condition and improve the results of treatment of patients with severe burn injury. Intra-abdominal hypertension is a frequent complication in severe burn patients requiring massive fluid resuscitation. Development of ACS in burn patients is associated with high mortality. Prevention, early detection and proper management may avoid this usually fatal complication. Fluid resuscitation volume is directly responsible for the development of ACS in severe burned patients. Thus, optimal fluid resuscitation can be the best prevention of IAH and ACS.

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Nonmedical Factors Influencing Early Deaths in Burns: A Study of the National Burn Repository

Journal of Burn Care & Research ◽

10.1093/jbcr/irz139 ◽

2019 ◽

Author(s):

Rachel M Nygaard ◽

Frederick W Endorf

Keyword(s):

Socioeconomic Factors ◽

Burn Injury ◽

Total Body Surface Area ◽

Early Period ◽

Inhalation Injury ◽

Burn Patients ◽

Commercial Insurance ◽

Severe Burns ◽

Hispanic Patients ◽

Major Factors

Abstract It is well-established that survival in burn injury is primarily dependent on three factors: age, percent total-body surface area burned (%TBSA), and inhalation injury. However, it is clear that in other (nonburn) conditions, nonmedical factors may influence mortality. Even in severe burns, patients undergoing resuscitation may survive for a period of time before succumbing to infection or other complications. In some cases, though, families in conjunction with caregivers may choose to withdraw care and not resuscitate patients with large burns. We wanted to investigate whether any nonmedical socioeconomic factors influenced the rate of early deaths in burn patients. The National Burn Repository (NBR) was used to identify patients that died in the first 72 hours after injury and those that survived more than 72 hours. Both univariate and multivariate regression analyses were used to examine factors including age, gender, race, comorbidities, burn size, inhalation injury, and insurance type, and determine their influence on deaths within 72 hours. A total of 133,889 burn patients were identified, 1362 of which died in the first 72 hours. As expected, the Baux score (age plus burn size), and inhalation injury predicted early deaths. Interestingly, on multivariate analysis, patients with Medicare (p = .002), self-pay patients (p < .001), and those covered by automobile policies (p = .045) were significantly more likely to die early than those with commercial insurance. Medicaid patients were more likely to die early, but not significantly (p = .188). Worker’s compensation patients were more likely to survive the first 72 hours compared with patients with commercial insurance (p < .001). Men were more likely to survive the early period than women (p = .043). On analysis by race, only Hispanic patients significantly differed from white patients, and Hispanics were more likely to survive the first 72 hours (p = .028). Traditional medical factors are major factors in early burn deaths. However, these results show that nonmedical socioeconomic factors including race, gender, and especially insurance status influence early burn deaths as well.

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Altered Expression of microRNAs in Serum Extracellular Vesicles in Rats with Severe Burns during Shock Stage

Current Molecular Medicine ◽

10.2174/1566524020666200712181644 ◽

2020 ◽

Vol 20 ◽

Author(s):

Mengru Dong ◽

Yanbin Gao ◽

Minxiong Li ◽

Lei Yang

Keyword(s):

Extracellular Vesicles ◽

Target Genes ◽

Early Stage ◽

Expression Profiles ◽

Total Body Surface Area ◽

Signal Pathways ◽

Burn Shock ◽

Severe Burn ◽

Altered Expression ◽

Severe Burns

Background: The shock stage of severe burns is a critical determinant of prognosis and the induction of systemic inflammatory response syndrome and multiple organ failure. Extracellular vesicles (EVs) containing abundant miRNAs are known to participate in various biological processes. Due to lack of researches in alternations of miRNAs in severe burns, our study analyzed the miRNA profiles of EVs in severe burns during shock stage. Methods: EVs were extracted from serum of rats with severe burns (30% of total body surface area, III°), and the expression of miRNAs in serum EVs was determined by next generation sequencing. Functional analysis of target genes of miRNAs that were significantly differentially expressed (DE) was performed using GO Ontology (GO) and Kyoto Encyclopedia of Genes and Genomes (KEGG). Results: Thirty-four DE miRNAs were identified at the early stage of severe burn shock and 63 at the late stage of severe burn shock. In addition, miRNA-339-5p, miRNA-1, miRNA-382-5p, miRNA134-5p, miRNA-133a-5p, and miRNA-365a5p were DE throughout the entire shock stage, based on P < 0.01 and |log2 (foldchange)| ≥ 1 criteria. GO and KEGG analysis revealed that the target genes of DE miRNAs mainly enriched metabolic process, immune system processes, and signal pathways. Conclusion: To our best knowledge, this is the first study demonstrating the miRNA expression profiles of EVs isolated from serum with severe burns during shock stage. There are significant differences in downregulation and upregulation. Thus, miRNAs have potential for novel biomarkers for the complication of severe burns.

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Serum Level of Musclin Is Elevated Following Severe Burn

Journal of Burn Care & Research ◽

10.1093/jbcr/irz101 ◽

2019 ◽

Vol 40 (5) ◽

pp. 535-540 ◽

Cited By ~ 1

Author(s):

Audra Clark ◽

Ryan M Huebinger ◽

Deborah L Carlson ◽

Steven E Wolf ◽

Juquan Song

Keyword(s):

Serum Level ◽

Burn Injury ◽

Total Body Surface Area ◽

Cytokine Profile ◽

C2c12 Myoblast ◽

Burn Patients ◽

Severe Burn ◽

Rat Serum ◽

Serum Stimulation

Abstract Muscle wasting induced by severe burn worsens clinical outcomes is associated with hyperglycemia. A novel muscle-specific secretory factor, musclin, was reported to regulate glucose metabolism with a homologous sequence of natriuretic peptides. The purpose of the study was to investigate musclin expression in response to burn injury in both human and animal models. Serum was collected from 13 adult burn patients and circulating levels of musclin protein were measured via elisa. The cytokine profile was measured by Bio-Plex multiple immunoassay. Following the clinical study, we used a burn rat model with 40% TBSA to study the time course of musclin expression till day 14. Rat serum and muscle tissue sample were harvested. Finally, an in vitro study was applied to investigate whether the muscle cell C2C12 myoblast expressed musclin under 10% burn serum stimulation. Pearson analysis showed that there was a significant positive correlation of musclin expression to total body surface area of burn in patients (P &= .038). Musclin expression was significantly positively correlated with IL-4, IL-7, IL-12, and IL-13 in burn patients’ serum (P < .05). In the animal study, we found that the musclin level evaluated at 6 hours and 1 day in burn rat serum (P < .05). In vitro, musclin mRNA expression significantly increased with burn serum stimulation at 24 hours (P < .05). In conclusion, serum level of musclin elevated both in human patients and burn animals; musclin was correlated with the severity of burn injury as well as with an elevated cytokine profile in patients; burn serum-stimulated musclin expression in vitro further identified the resource of musclin expression after burn.

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Nutrition Therapy in Type 2 Diabetic Burn Patient

Jurnal Plastik Rekonstruksi ◽

10.14228/jprjournal.v8i1.314 ◽

2021 ◽

Vol 8 (1) ◽

pp. 21-24

Author(s):

Dian Araminta Ramadhania ◽

Aditya Wardhana ◽

Wina Sinaga ◽

Yohannessa Wulandari ◽

Mulianah Daya ◽

...

Keyword(s):

Diabetes Mellitus ◽

Unsaturated Fatty Acids ◽

Burn Injury ◽

Total Body Surface Area ◽

Nutrition Therapy ◽

Positive Trend ◽

Personalized Nutrition ◽

Severe Burn ◽

Metabolic Conditions

Summary: Severe burn patients experience pronounced metabolic changes that caused hyperglycemia. Other existing metabolic conditions such as diabetes mellitus may worsen this condition. Early, adequate, and personalized nutrition therapy may result in better glycemic control and prognosis.A 44-year-old male with severe burn injury involving 27,5% total body surface area (TBSA) and type 2 diabetes mellitus (T2DM) was given early and diabetes-specific nutrition therapy to meet the recommended energy and protein needs. Lower carbohydrate contents and higher mono-unsaturated fatty acids (MUFA) were components of diabetes-specific nutrition therapy. Desirable blood glucose levels, a positive trend of albumin levels, and reduced inflammatory markers were achieved while being given this nutrition therapy. Sepsis was not diagnosed in this patient. The patient was discharged from the hospital after an improvement in clinical condition. Hyperglycemia commonly occurs in critically ill patients, especially with pre-existing T2DM. The provision of prompt and personalized nutrition therapy will improve clinical outcomes.

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11 Vitamin D Deficiency on Admission and the Association with Length of Stay in Patients with Thermal Injury: A Multi-center Analysis

Journal of Burn Care & Research ◽

10.1093/jbcr/irab032.016 ◽

2021 ◽

Vol 42 (Supplement_1) ◽

pp. S13-S14

Author(s):

Sarah Zavala ◽

Kate Pape ◽

Todd A Walroth ◽

Melissa A Reger ◽

Katelyn Garner ◽

...

Keyword(s):

Vitamin D ◽

Length Of Stay ◽

Vitamin D Deficiency ◽

Burn Injury ◽

Total Body Surface Area ◽

Inhalation Injury ◽

Hospital Length Of Stay ◽

Burn Patients ◽

Comfort Care ◽

The Impact

Abstract Introduction In burn patients, vitamin D deficiency has been associated with increased incidence of sepsis. The objective of this study was to assess the impact of vitamin D deficiency in adult burn patients on hospital length of stay (LOS). Methods This was a multi-center retrospective study of adult patients at 7 burn centers admitted between January 1, 2016 and July 25, 2019 who had a 25-hydroxyvitamin D (25OHD) concentration drawn within the first 7 days of injury. Patients were excluded if admitted for a non-burn injury, total body surface area (TBSA) burn less than 5%, pregnant, incarcerated, or made comfort care or expired within 48 hours of admission. The primary endpoint was to compare hospital LOS between burn patients with vitamin D deficiency (defined as 25OHD < 20 ng/mL) and sufficiency (25OHD ≥ 20 ng/mL). Secondary endpoints include in-hospital mortality, ventilator-free days of the first 28, renal replacement therapy (RRT), length of ICU stay, and days requiring vasopressors. Additional data collected included demographics, Charlson Comorbidity Index, injury characteristics, form of vitamin D received (ergocalciferol or cholecalciferol) and dosing during admission, timing of vitamin D initiation, and form of nutrition provided. Dichotomous variables were compared via Chi-square test. Continuous data were compared via student t-test or Mann-Whitney U test. Univariable linear regression was utilized to identify variables associated with LOS (p < 0.05) to analyze further. Cox Proportional Hazard Model was utilized to analyze association with LOS, while censoring for death, and controlling for TBSA, age, presence of inhalation injury, and potential for a center effect. Results Of 1,147 patients screened, 412 were included. Fifty-seven percent were vitamin D deficient. Patients with vitamin D deficiency had longer LOS (18.0 vs 12.0 days, p < 0.001), acute kidney injury (AKI) requiring RRT (7.3 vs 1.7%, p = 0.009), more days requiring vasopressors (mean 1.24 vs 0.58 days, p = 0.008), and fewer ventilator free days of the first 28 days (mean 22.9 vs 25.1, p < 0.001). Univariable analysis identified burn center, AKI, TBSA, inhalation injury, admission concentration, days until concentration drawn, days until initiating supplementation, and dose as significantly associated with LOS. After controlling for center, TBSA, age, and inhalation injury, the best fit model included only deficiency and days until vitamin D initiation. Conclusions Patients with thermal injuries and vitamin D deficiency on admission have increased length of stay and worsened clinical outcomes as compared to patients with sufficient vitamin D concentrations.

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Activity Impairment, Work Status, and Work Productivity Loss in Adults 5–7 Years After Burn Injuries

Journal of Burn Care & Research ◽

10.1093/jbcr/irab047 ◽

2021 ◽

Author(s):

Inge Spronk ◽

Nancy EE Van Loey ◽

Cornelis H van der Vlies ◽

Juanita A Haagsma ◽

Suzanne Polinder ◽

...

Keyword(s):

Productivity Loss ◽

Total Body Surface Area ◽

Work Productivity ◽

Burn Injuries ◽

Work Status ◽

Burn Patients ◽

Work Situation ◽

Activity Impairment ◽

Severe Burns ◽

Specific Health

Abstract An important aspect of the rehabilitation of burn patients is social participation, including daily activities and work. Detailed information on long-term activity impairment and employment is scarce. Therefore, we investigated activity impairment, work status, and work productivity loss in adults 5–7 years following burn injuries, and investigated associations with burn-specific health-related quality of life (HRQL) domains. Adult participants completed the Work Productivity and Activity Impairment General Health questionnaire and the Burn Specific Health Scale-brief (BSHS-B) 5–7 years post-burn. Outcomes were compared between participants with mild/intermediate and severe burns (>20% total body surface area burned). Seventy-six (36%) of the 213 participants experienced some degree of activity impairment due to burn-related problems 5–7 years post-burn. Seventy percent of the population was employed; 12% of them experienced work productivity loss due to burn-related problems. Nineteen percent reported changes in their work situation (partly) because of the burn injury. A higher proportion of participants with severe burns had activity impairments (56% vs 29%; P = .001) and work productivity loss (26% vs 8%; P < .001) compared to participants with mild/intermediate burns. Activity impairment and work productivity loss were both associated with burn-related work problems and lower mood, measured with the BSHS-B. In conclusion, a substantial part of the study population experienced activity impairment and work productivity loss, was unemployed, and/or reported changes in their work situation due to their injury. Particularly patients with severe burns reported productivity loss and had lower employment rates. This subscribes the importance of addressing work-related functioning in the rehabilitation of burn patients.

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Epidemiology of injuries, treatment (costs) and outcome in burn patients admitted to a hospital with or without dedicated burn centre (Burn-Pro): protocol for a multicentre prospective observational study

BMJ Open ◽

10.1136/bmjopen-2018-023709 ◽

2018 ◽

Vol 8 (11) ◽

pp. e023709 ◽

Cited By ~ 1

Author(s):

Esther MM Van Lieshout ◽

Daan T Van Yperen ◽

Margriet E Van Baar ◽

Suzanne Polinder ◽

Doeke Boersma ◽

...

Keyword(s):

Quality Of Life ◽

Observational Study ◽

Prospective Observational Study ◽

Burn Injury ◽

Treatment Costs ◽

Burn Patients ◽

Severe Burns ◽

Referral Criteria ◽

Age Limit

IntroductionThe Emergency Management of Severe Burns (EMSB) referral criteria have been implemented for optimal triaging of burn patients. Admission to a burn centre is indicated for patients with severe burns or with specific characteristics like older age or comorbidities. Patients not meeting these criteria can also be treated in a hospital without burn centre. Limited information is available about the organisation of care and referral of these patients. The aims of this study are to determine the burn injury characteristics, treatment (costs), quality of life and scar quality of burn patients admitted to a hospital without dedicated burn centre. These data will subsequently be compared with data from patients with<10% total bodysurface area (TBSA) burned who are admitted (or secondarily referred) to a burn centre. If admissions were in agreement with the EMSB, referral criteria will also be determined.Methods and analysisIn this multicentre, prospective, observational study (cohort study), the following two groups of patients will be followed: 1) all patients (no age limit) admitted with burn-related injuries to a hospital without a dedicated burn centre in the Southwest Netherlands or Brabant Trauma Region and 2) all patients (no age limit) with<10% TBSA burned who are primarily admitted (or secondarily referred) to the burn centre of Maasstad Hospital. Data on the burn injury characteristics (primary outcome), EMSB compliance, treatment, treatment costs and outcome will be collected from the patients’ medical files. At 3 weeks and at 3, 6 and 12 months after trauma, patients will be asked to complete the quality of life questionnaire (EuroQoL-5D), and the patient-reported part of the Patient and Observer Scar Assessment Scale (POSAS). At those time visits, the coordinating investigator or research assistant will complete the observer-reported part of the POSAS.Ethics and disseminationThis study has been exempted by the medical research ethics committee Erasmus MC (Rotterdam, The Netherlands). Each participant will provide written consent to participate and remain encoded during the study. The results of the study are planned to be published in an international, peer-reviewed journal.Trial registration numberNTR6565.

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