13 Macronutrient Intake and Wound Healing in Critically Ill Burn Patients

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S11-S12
Author(s):  
Sarah S Rupert ◽  
Beth A Shields ◽  
Brenda D Bustillos ◽  
Leopoldo C Cancio
Keyword(s):  
Wound Healing ◽  
Logistic Regression ◽  
Enteral Nutrition ◽  
Critically Ill ◽  
Univariate Analysis ◽  
Total Body Surface Area ◽  
Oral Intake ◽  
Nutrition Support ◽  
Burn Patients ◽  
Macronutrient Intake

Abstract Introduction Nutrition support is an important component of the care of the critically ill burn patient. The European Society for Parenteral and Enteral Nutrition recommends less than 35% of calories from fat and less than 60% from carbohydrate (CHO); however, favorable clinical outcomes have been found in randomized controlled trials when burn patients were given 12–27% fat and 46–65% CHO. These benefits include lower rates of pneumonia and mortality. The purpose of this research was to examine macronutrient intake of critically ill burn patients and the association with wound healing. Methods A retrospective study was approved by the Institutional Review Board and included patients admitted to our burn intensive care unit over an 11 year period who were ≥18 years of age, had ≥20% total body surface area burns. Subjects who required hospitalization for ≥8 days and required nutrition support were included in this analysis. Subjects who were admitted over a week after injury and those who underwent limb amputations were excluded. Caloric intake from CHO, fat, and protein was obtained from enteral nutrition, parenteral nutrition, and oral intake for the first eight days following hospitalization. Wound healing was defined as achieving < 10% TBSA open wound. Univariate analysis was used to identify factors significantly associated with wound healing. Variables found to be significant (p< 0.05) were subjected to logistic regression. Results A total of 309 patients (89% male) were included. Patients were 37 ± 17 years old and had 46 ± 18% TBSA burns. Wound healing was achieved by 77% of patients, with 26% mortality. Those who healed were significantly younger (34 ± 15 vs. 47 ± 19 years, p< 0.001), were taller (70 ± 3 vs. 68 ± 4 inches, p< 0.001), with smaller burns (44 ± 16% vs. 54 ± 20% TBSA, p< 0.001), predominantly male (92% vs. 77%, p< 0.001), received a higher amount of CHO (1166 ± 465 vs. 902 ± 494 kcals, p< 0.001), and received a higher amount of fat (455 ± 234 vs. 360 ± 220 kcals, p=0.003). After logistic regression, factors negatively associated with wound healing included increased age (p< 0.001), female gender (p=0.032), and larger burn size (p< 0.001); a positive association was seen with 8-day average calories from CHO (p=0.027). Conclusions This study identified several factors significantly associated with healing in burn patients; however, higher CHO intake was the only modifiable factor. Further research is needed to determine the optimal CHO intake to improve patient outcomes. Applicability of Research to Practice Consideration should be made for high-CHO enteral nutrition in critically ill burn patients.

817 A Proactive Feeding Regimen on Meeting Caloric Goals with Continuous Enteral Nutrition Support: A Quality Improvement Project

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S247-S248
Author(s):  
Elizabeth Lu
Keyword(s):  
Quality Improvement ◽  
Enteral Nutrition ◽  
Total Body Surface Area ◽  
Quality Improvement Project ◽  
Nutrition Support ◽  
Burn Patients ◽  
Improvement Project ◽  
Impaired Wound Healing ◽  
Protocol Group ◽  
Increased Risk

Abstract Introduction Severe burn injuries are characterized by elevated metabolic demands. Numerous studies have documented iatrogenic underfeeding of critical care patients, which can lead to malnutrition, impaired wound healing, weakened immune response, and increased risk of infections. Enteral nutrition (EN) support is often utilized to help meet the increased caloric demands of burn patients. However, discrepancies between prescribed and delivered EN can occur due to frequent interruptions, delays initiating EN, gradual advancement of EN rate, and/or physician directed changes. The objective of this quality improvement project is to assess whether a proactive calculation of EN regimens can improve the provision of calories compared to a traditional calculation method. Methods A retrospective review of patients in a pediatric acute burn unit that received continuous EN for greater than three days was performed. The pre-protocol group consisted of patients from January 1st, 2017 to November 30th, 2017 who had continuous EN rates calculated by the dietitian based on 24 hours per day. This group was compared to patients from September 1st, 2018 to July 31st, 2019 who had EN rates calculated by the dietitian based on 23 hours per day (post-protocol group). Periods in which parenteral nutrition was administered or the EN regimen was prescribed in a non-continuous fashion were excluded. The primary outcome measure was the percentage of admissions in which patients met at least 85% of calorie estimations. This project was undertaken as a Quality Improvement initiative and, as such, was not formally supervised by an Institutional Review Board. Results A total of 132 patients (73 pre- and 59 post-protocol) from 134 separate inpatient admissions (73 pre- and 61 post-protocol) were identified. The average total body surface area burn was 40.9% (SD 18.8) vs. 49.4% (SD 19.8) and average age was 8.6 years (SD 5.9) vs. 7.9 years (SD 5.4) in the pre- and post-protocol groups, respectively. Continuous EN ran for an average of 20 hours a day (SD 2.2, median = 21) vs. 21 hours a day (SD 2.7, median = 22) in the pre- and post-protocol groups, respectively. The average number of days on continuous EN was comparable in both groups. The post-protocol group had 75% of admissions meet at least 85% of calorie estimations compared to the pre-protocol group with 52% of admissions having met the goal. Conclusions Due to the heightened metabolic demands of burn patients and the barriers to meeting caloric goals, it is important to minimize calorie deficits with EN support. Although a seemingly small change, calculating continuous EN rates based on 23 hours per day can yield improved caloric provisions compared to rates based on 24 hours per day. Applicability of Research to Practice A proactive approach to calculating continuous EN support should be considered to help decrease caloric deficits.

scholarly journals Early versus delayed enteral nutrition support for critically ill adults

2016 ◽  
Author(s):  
Paulina Fuentes Padilla ◽  
Gabriel Martínez ◽  
Robin WM Vernooij ◽  
Gerard Urrútia ◽  
Marta Roqué i Figuls ◽  
...  
Keyword(s):  
Enteral Nutrition ◽  
Critically Ill ◽  
Nutrition Support ◽  
Critically Ill Adults ◽  
Enteral Nutrition Support ◽  
Ill Adults

The Benefits of Parenteral Nutrition (PN) Versus Enteral Nutrition (EN) Among Adult Critically Ill Patients: What is the Evidence? A Literature Review

2019 ◽  
Vol 35 (7) ◽  
pp. 615-626 ◽  
Author(s):  
Angel Joel Cadena ◽  
Sara Habib ◽  
Fred Rincon ◽  
Stephanie Dobak
Keyword(s):  
Health Care ◽  
Intensive Care Unit ◽  
Intensive Care ◽  
Enteral Nutrition ◽  
Parenteral Nutrition ◽  
Clinical Outcomes ◽  
Critically Ill ◽  
Nutrition Support ◽  
Mechanical Ventilation Duration ◽  
The Impact

Malnutrition is frequently seen among patients in the intensive care unit. Evidence shows that optimal nutritional support can lead to better clinical outcomes. Recent clinical trials debate over the efficacy of enteral nutrition (EN) over parenteral nutrition (PN). Multiple trials have studied the impact of EN versus PN in terms of health-care cost and clinical outcomes (including functional status, cost, infectious complications, mortality risk, length of hospital and intensive care unit stay, and mechanical ventilation duration). The aim of this review is to address the question: In critically ill adult patients requiring nutrition support, does EN compared to PN favorably impact clinical outcomes and health-care costs?

scholarly journals A comparative study to evaluate the effect of honey dressing and silver sulfadiazene dressing on wound healing in burn patients

2009 ◽  
Vol 42 (02) ◽  
pp. 176-181
Author(s):  
P. S. Baghel ◽  
S. Shukla ◽  
R. K. Mathur ◽  
R. Randa
Keyword(s):  
Wound Healing ◽  
Average Duration ◽  
Total Body Surface Area ◽  
Burn Patients ◽  
The Mean ◽  
Total Body ◽  
Time Of Admission ◽  
And Control ◽  
Burn Contractures

ABSTRACTTo compare the effect of honey dressing and silver-sulfadiazene (SSD) dressing on wound healing in burn patients. Patients (n=78) of both sexes, with age group between 10 and 50 years and with first and second degree of burn of less than 50% of TBSA (Total body surface area) were included in the study, over a period of 2 years (2006-08). After stabilization, patients were randomly attributed into two groups: ‘honey group’ and ‘SSD group’. Time elapsed since burn was recorded. After washing with normal saline, undiluted pure honey was applied over the wounds of patients in the honey group (n=37) and SSD cream over the wounds of patients in SSD group (n=41), everyday. Wound was dressed with sterile gauze, cotton pads and bandaged. Status of the wound was assessed every third and seventh day and on the day of completion of study. Patients were followed up every fortnight till epithelialization. The bacteriological examination of the wound was done every seventh day. The mean age for case (honey group) and control (SSD group) was 34.5 years and 28.5 years, respectively. Wound swab culture was positive in 29 out of 36 patients who came within 8 hours of burn and in all patients who came after 24 hours. The average duration of healing in patients treated with honey and SSD dressing at any time of admission was 18.16 and 32.68 days, respectively. Wound of all those patients (100%) who reported within 1 hour became sterile with honey dressing in less than 7 days while none with SSD. All of the wounds became sterile in less than 21 days with honey, while tthis was so in only 36.5% with SSD treated wounds. The honey group included 33 patients reported within 24 hour of injury, and 26 out of them had complete outcome at 2 months of follow-up, while numbers for the SSD group were 32 and 12. Complete outcome for any admission point of time after 2 months was noted in 81% and 37% of patients in the honey group and the SSD group. Honey dressing improves wound healing, makes the wound sterile in lesser time, has a better outcome in terms of prevention of hypertrophic scarring and post-burn contractures, and decreases the need of debridement irrespective of time of admission, when compared to SSD dressing.

Parenteral nutrition in the ICU

2016 ◽  
Author(s):  
Jonathan Cohen ◽  
Shaul Lev
Keyword(s):  
Animal Models ◽  
Enteral Nutrition ◽  
Parenteral Nutrition ◽  
Critically Ill ◽  
Critically Ill Patients ◽  
Nutrition Support ◽  
Glutamine Supplementation ◽  
Artificial Nutrition ◽  
Omega 3 ◽  
Aspen Guidelines

Parenteral nutrition (PN) is a technique of artificial nutrition support, which consists of the intravenous administration of macronutrients, micronutrients, and water. PN has become integrated into intensive care unit (ICU) patient management with the aim of preventing energy deficits and preserving lean body mass. The addition of PN to enteral nutrition is known as supplemental PN. Parenteral feeding should be considered whenever enteral nutritional support is contraindicated, or when enteral nutrition alone is unable to meet energy and nutrient requirements. International guidelines differ considerably regarding the indications for PN. Thus, the ESPEN guidelines recommend initiating PN in critically-ill patients who do not meet caloric goals within 2–3 days of commencing EN, while the Canadian guidelines recommend PN only after extensive attempts to feed with EN have failed. The ASPEN guidelines advocate administering PN after 8 days of attempting EN unsuccessfully. Several studies have demonstrated that parenteral glutamine supplementation may improve outcome, and the ESPEN guidelines give a grade A recommendation to the use of glutamine in critically-ill patients who receive PN. Studies on IV omega-3 fatty acids have yielded promising results in animal models of acute respiratory distress syndrome and proved superior to solutions with omega -6 compositions. The discrepancy between animal models and clinical practice could be related to different time frames.

1 The Impact of No Next of Kin Decision Makers on End-of-life Care

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S4-S5
Author(s):  
Ryan K Ota ◽  
Maxwell B Johnson ◽  
Trevor A Pickering ◽  
Warren L Garner ◽  
Justin Gillenwater ◽  
...  
Keyword(s):  
Critically Ill ◽  
Decision Maker ◽  
Total Body Surface Area ◽  
Burn Patients ◽  
Inclusion Criteria ◽  
Next Of Kin ◽  
Medical Decisions ◽  
Comfort Care ◽  
Burn Care ◽  
The Impact

Abstract Introduction For critically ill burn patients without a next of kin (NOK), the medical team is tasked with becoming the surrogate decision maker. This poses difficult ethical and legal challenges for burn providers. Despite this frequent problem, there has been no investigation of how the presence of a NOK affects treatment in burn patients. This study is the first to evaluate this relationship. Methods A retrospective chart review was performed on a cohort of patients who died during the acute phase of their burn care from a single burn center from 2015 to 2019. Inclusion criteria were age ≥18 years and mortality within 4-weeks of admission. Exclusion criteria were death from dermatologic disease or trauma. Variables collected included age, gender, mechanism of injury, length of stay (LOS), total body surface area (TBSA), revised Baux score, and the presence of a NOK. Fisher’s Exact Test and Student’s t-test were used for analysis. Results In total, 67 patients met inclusion criteria. Of these patients, 14 (21%) did not have a NOK involved in medical decisions. Table 1 shows the means and odds ratio between the two groups. Patients without a NOK were younger (p < 0.05), more likely to be homeless (p < 0.01), had higher TBSA (p < 0.01), had shorter LOS (p < 0.01), and were 5 times less likely to receive comfort care (p < 0.05). Gender and ethnicity were not statistically significant. Conclusions Patients without a NOK present to participate in medical decisions are transitioned to comfort care less often despite having a higher burden of injury. This disparity in standard of care between the two groups demonstrates a need for a cultural shift in burn care to prevent suffering of these marginalized patients. Burn providers should be empowered to reduce suffering when no decision maker is present. Applicability of Research to Practice We report that the absence of a NOK has a significant impact leading to a decreased initiation of comfort care in critically ill burn patients. National protocols should be created to allow burn providers to act as a surrogate to prevent prolonged suffering.

Safety and Tolerance of Intraoperative Enteral Nutrition Support in Pediatric Burn Patients

2019 ◽  
Vol 34 (5) ◽  
pp. 728-734 ◽  
Author(s):  
Christina A. Sunderman ◽  
Michele M. Gottschlich ◽  
Chris Allgeier ◽  
Glenn Warden
Keyword(s):  
Enteral Nutrition ◽  
Nutrition Support ◽  
Burn Patients ◽  
Enteral Nutrition Support
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