15 Nutrition Therapy in the Burn Care Setting: What Is Best Achievable Practice?

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S12-S13
Author(s):  
Daren Heyland ◽  
Luis A Ortiz ◽  
Warren L Garner ◽  
Samuel P Mandell ◽  
Kirsten Colpaert ◽  
...  
Keyword(s):  
Clinical Outcomes ◽  
Oral Intake ◽  
Nutrition Therapy ◽  
Burn Injuries ◽  
Artificial Nutrition ◽  
Apache Ii Score ◽  
Burn Patients ◽  
Nutrient Deficiencies ◽  
Nutritional Adequacy ◽  
Burn Care

Abstract Introduction The fourth most common injury worldwide are burn injuries. The uncontrolled inflammation, hyper-catabolism, and nutrient deficiencies associated with burn injuries can translate into worse clinical outcomes. Accordingly, CPGs recommends increasing energy requirements from 25–35 kcal/kg/day and provide 1.5–2 grams of protein/kg/day. Thus, the aim of this research is to evaluate the adherence level to CPGs recommendations in adult burn patients and describe the nutritional variability intake across Burn Units (BU) in North America (NA), Latin America (LATAM), and Europe (EU). Methods In a multi-national, multi-centre (n=43), double-blinded, controlled RCT of adult burn patients randomly allocated to receive either L-glutamine (0.5g/kg/day) or placebo via enteral nutrition (EN), we explored the nutritional adequacy. Patients with a deep 2nd-3rd degree burns were enrolled. Patients with renal failure, electrical injuries, BMI < 18 or > 50, liver cirrhosis, contraindication for EN, pregnancy, or moribund were excluded. BUs with >5 burn patients with completed data were included in this analysis. Patient demographics, nutritional intake and clinical outcomes were collected. Nutritional adequacy was calculated from all sources (glucose and oral intake no collected). Descriptive analyses for quantitative data were performed. The data is presented as mean and standard deviation (±) or median with interquartile range [25th to 75th percentile] Results Six hundred and eight burn patients from 32 BUs were included. Overall, 75% (n=455) of the patients were male and Caucasians (78% [n=477]) with a median age of 51 [34–64] years, moderately ill (12 [8–19] APACHE II score), and the most common type of burn was fire (87% [n=530]) with a %TBSA of 27 [20–40], Table 1. Overall, 242 (40%) patients received artificial nutrition. The proportion of patients receiving EN alone at each BU averaged 84% [worst: 7% to best site:88%]. Overall, time from admission to start of EN was an average of 0.7 [0.4 – 0.9] days across all BUs [best:0.2 to worst site: 1.7 day]. PN+EN was used on 13% (n=31) of the patients [site range, 5–89%]. Average adequacy of calories at all sites was 71 % (site average range, 22–82 %) and 72 % (29%– 97%) for protein with greater adequacy observed in LATAM BUs and worst adequacy observed in NA BUs, Figure 1. At the site level, a total of 7 (21%) and 9 (28%) BU successfully achieved >80% of calories and protein via artificial nutrition, respectively, Figure 2. The average use of motility agents in patients receiving >80% at site level was 72 [60–85 %]. Conclusions The actual energy and protein intake remains suboptimal in burn patients worldwide but tremendous variability exists across BU worldwide. Efforts to standardize and enhance EN delivery are warranted. Applicability of Research to Practice Compliance with clinical guidelines recommendations might improve clinical outcomes in burn victims.

88 Validation of the Modified NUTrition Risk Score (mNUTRIC) in Burn Victims: Evidence from a Multi-centre, Multi-national, Double-blind, Controlled Randomized Clinical Trial

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S58-S59
Author(s):  
Daren Heyland ◽  
Luis A Ortiz ◽  
Alexis F Turgeon ◽  
Lucy Wibbenmeyer ◽  
Jonathan Pollack ◽  
...  
Keyword(s):  
High Risk ◽  
Clinical Outcomes ◽  
Total Body Surface Area ◽  
Average Energy ◽  
Nutrition Therapy ◽  
Hospital Length Of Stay ◽  
Nutritional Adequacy ◽  
Double Blind ◽  
Intravenous Glucose ◽  
Burn Victims

Abstract Introduction Nutrition is an essential therapy in burn victims. However, whether nutrition therapy provide benefits equally to all burn victims is unknown. The NUTRIC score identifies patients who may not benefit more from aggressive nutrition therapy (score < 5) and those who may benefit more from aggressive nutrition (High score ≥ 5). It can be estimated from age, SOFA, APACHE scores, comorbidities, and IL-6. If the latter is not available, the modified NUTRIC score (mNUTRIC) can be computed. The mNUTRIC score has been validated in ICU settings. In burn victims, the association between mNUTRIC score, nutritional intake, and clinical outcomes is unknown. We hypothesize that a higher mNUTRIC score will be associated with worst clinical outcomes and that greater nutritional adequacy will be associated with better clinical outcomes in nutritionally high-risk burn victims. Methods In the context of a double-blind, placebo-active, multi-centre RCT of adult burn patients, we evaluated the association between mNUTRIC score, nutritional adequacy, and clinical outcomes. Patients with deep second and/or third-degree burns with a total body surface area percentage (TBSA%) ≥10 were enrolled in the RCT. Patients demographics, type of burn, %TBSA, nutrition intake, hospital length of stay (LOS), Burn Unit (BU) LOS, and hospital mortality were collected. The nutritional adequacy was calculated from all sources, except intravenous glucose and oral intake. Descriptive and inferential analyses for quantitative data were performed. Results Six hundred and sixty patients were included. The majority were Caucasian (78%) males (74%) with a BMI between 25–35 (53%), median age of 50 ±18 years and severely ill (Apache Score II; 14 ±8, SOFA score; 2.9 ±3). The most common type of burn was fire (87%), with %TBSA of 31 ±16, Table 1. EN alone was provided to 79% of the patients and the daily average energy and protein adequacy was 73% and 76%, accordingly. Table 2. Compared to low mNUTRIC, the high mNUTRIC group had less ventilator free days (11 [6–19] vs. 28 [11–28] days), worse survival (52% vs. 9.5%), and longer hospital LOS (181 [81–181] vs. 34 [20–68] days), Table 3. Compared to the low mNUTRIC, the high mNUTRIC group had better clinical outcomes with increasing energy (by 20% of goal), interaction for energy, mNUTRIC, and mortality was p=0.11 and for time-discharge-alive was < p=0.0001. Similarly, more protein tended towards better outcomes in the high mNUTRIC group but not the low NUTRIC group (interaction for protein, mNUTRIC, mortality was p=0.20; time-to-discharge alive was p=0.08, Table 4. Conclusions A high mNUTRIC score identifies high risk burn victims and may identify those who may benefit more from an aggressive nutrition therapy. Applicability of Research to Practice Nutrition therapy in burns can be more efficient.

scholarly journals A Review of Burn Patients Requiring Extracorporeal Membrane Oxygenation at a Burns Facility

2021 ◽  
Vol 2 (4) ◽  
pp. 293-300
Author(s):  
Stephen Frost ◽  
Liz Davies ◽  
Claire Porter ◽  
Avinash Deodhar ◽  
Reena Agarwal
Keyword(s):  
Extracorporeal Membrane Oxygenation ◽  
Burn Injury ◽  
Burn Injuries ◽  
Burn Patients ◽  
Review Of The Literature ◽  
Respiratory Compromise ◽  
Burn Care ◽  
Membrane Oxygenation ◽  
Regular Time ◽  
Major Burn

Respiratory compromise is a recognised sequelae of major burn injuries, and in rare instances requires extracorporeal membrane oxygenation (ECMO). Over a ten-year period, our hospital trust, an ECMO centre and burns facility, had five major burn patients requiring ECMO, whose burn injuries would normally be managed at trusts with higher levels of burn care. Three patients (60%) survived to hospital discharge, one (20%) died at our trust, and one patient died after repatriation. All patients required regular, time-intensive dressing changes from our specialist nursing team, beyond their regular duties. This review presents these patients, as well as a review of the literature on the use of ECMO in burn injury patients. A formal review of the overlap between the networks that cater to ECMO and burn patients is recommended.

588 Peripheral Nerve Blocks in Procedural Care for Burn Injuries Less Than 10% Total Burn Surface Area: A Retrospective Chart Review.

2021 ◽  
Vol 42 (Supplement_1) ◽  
pp. S145-S146
Author(s):  
Kimberly Maynell ◽  
Khattiya Chharath ◽  
Thanh Tran ◽  
Loryn Taylor ◽  
David J Smith
Keyword(s):  
Pain Management ◽  
Pain Intensity ◽  
Hospital Discharge ◽  
Burn Injuries ◽  
Burn Patients ◽  
Nerve Blocks ◽  
Peripheral Nerve Blocks ◽  
Burn Care ◽  
Analgesic Consumption ◽  
Significant Difference

Abstract Introduction Pain control remains one of the major challenges in management of burn patients. Pain associated with procedural and post-procedural burn care such as excision and grafting, postoperative dressing changes, and postoperative physical therapies often requires patients to be on intravenous and oral analgesics leading to potential long-term dependence after hospital discharge. Peripheral nerve blocks (PNB) use for perioperative pain management in burn patients may present an alternative pain management modality to help decrease analgesic consumption and shorten length of stay following procedural care. Our hypothesis was tested by evaluating the outcomes from implementation of PNB with ultrasound guided catheter placement for burn procedural care in patients with ≤ 10% total burn surface area (TBSA) requiring excision and grafting. Methods After IRB approval, we retrospectively collected demographics, medical history, pain intensity (rated as “No Pain” [NRS=0], “Minor Pain” [NRS 1 to 3], “Moderate Pain” [NRS 4 to 6], “Severe Pain” [NRS 7 to 10]), postoperative analgesic consumption and time to hospital discharge of patients who underwent autografting procedures for burn injuries ≤ 10% TBSA from October 1, 2019 to December 31, 2019 (the start of our implementation of PNB for procedural burn care). Data was analyzed using chi square/Fisher exact test for categorical variables and t-test for continuous variables. Results Our preliminary data included 20 patients (10 patients had PNB) with average age of 53 years, 60% males and average TBSA of 4.8%. Patients in both PNB and non-PNB groups had unremarkable medical histories and scald and flame as mechanism of burns. There was no significant difference in TBSA (5.3% TBSA in PNB and 4.8% TBSA in non-PNB). Pain intensity before autografting procedure for both groups were reported as moderate to severe and managed with fentanyl, morphine, oxycodone, along with ibuprofen and acetaminophen. There was no significant difference in postoperative pain intensity and opioid consumptions; however, postoperative acetaminophen consumption was less in PNB group compared to non-PNB group (2762±3646 mg vs 3932±7511 mg, respectively), although not statistically significant. There was no significant difference between time from surgery to first physical therapy session; however, time to hospital discharge was shorter in PNB group compared to non-PNB group (5.7±1 days vs 10.5±9 days, respectively), although not statistically significant. Conclusions This evaluation shows a trend in reduction of inpatient postoperative analgesic consumption as well as time to hospital discharge with the use of PNB, although a bigger sample size is needed for further assessment.

scholarly journals The Effect of Transfer on Outcomes in Burns

2021 ◽  
Author(s):  
Nathan E Bodily ◽  
Elizabeth H Bruenderman ◽  
Neal Bhutiani ◽  
Selena The ◽  
Jessica E Schucht ◽  
...  
Keyword(s):  
Total Body Surface Area ◽  
Infectious Complications ◽  
Burn Injuries ◽  
Burn Patients ◽  
Burn Care ◽  
Burn Center ◽  
Field Versus ◽  
High Acuity ◽  
Total Body ◽  
Inhalation Burn

Abstract Patients with burn injuries are often initially transported to centers without burn capabilities, requiring subsequent transfer to a higher level of care. This study aimed to evaluate the effect of this treatment delay on outcomes. Adult burn patients meeting American Burn Association (ABA) criteria for transfer at a single burn center were retrospectively identified. A total of 122 patients were evenly divided into two cohorts – those directly admitted to a burn center from the field, versus those transferred to a burn center from an outlying facility. There was no difference between the transfer and direct admit cohorts with respect to age, percent total body surface area burned, concomitant injury, or intubation prior to admission. Transfer patients experienced a longer median time from injury to burn center admission (1 vs. 8 hours, p &lt, 0.01). Directly admitted patients were more likely to have inhalation burn (18 vs. 4, p &lt, 0.01), require intubation after admission (10 vs. 2, p = 0.03), require an emergent procedure (18 vs. 5, p &lt, 0.01), and develop infectious complications (14 vs. 5, p = 0.04). There was no difference in ventilator days, number of operations, length of stay, or mortality. The results suggest that significantly injured, high acuity burn patients were more likely to be immediately identified and taken directly to a burn center. Patients who otherwise met ABA criteria for transfer were not affected by short delays in transfer to definitive burn care.

745 Pediatric Burn Transfers: A 10 Year Analysis of Adherence to ABA Transfer Criteria

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S205-S206
Author(s):  
Janine Roller ◽  
Rebecca Courtemanche ◽  
Marija Bucevska ◽  
Sally Hynes
Keyword(s):  
Pediatric Patients ◽  
Burn Injuries ◽  
Physician Education ◽  
Accurate Estimation ◽  
Burn Patients ◽  
Burn Care ◽  
The Past ◽  
Medical Disorders ◽  
Referral Criteria ◽  
Burn Depth

Abstract Introduction Severe burn injuries require complex care at certified burn centres to minimize morbidity and mortality. The ABA Burn Centre Referral Criteria was developed to aid clinicians in determining which patients warrant transfer as physician comfort with the management of pediatric burns, accurate estimation of TBSA, and burn depth varies. We hypothesize that pediatric patients are often transferred despite not meeting referral criteria. The aim of this study was to review pediatric patients with burn injuries that were transferred to the provincial burn centre over the past 10 years to better understand the reasons for the transfer. Methods A 10-year retrospective review from January 2008 to December 2018 was performed using the provincial Burn Registry. Pediatric burn patients under 18 years old who were transferred for burn care were identified and their demographics, burn characteristics, and the basis for transfer was analyzed against the ABA Burn Referral Criteria. Results A total of 130 pediatric burn patients were transferred from 42 different hospitals of varying trauma levels. Patients on average were 5 years old, predominantly male (59%), and scalds were the most common etiology (53%). Most patients were transferred by a fixed-wing ambulance (54%) and the average transport time was 1.5 days after the initial injury. All children met 1 or more ABA Referral Criteria for transfer. The most common reasons for transfer were for a TBSA greater than 10% (42.2%), burn to the hand (27.7%) or perineum (11.5%), 3° burn depth (12.3%), or significant pre-existing medical disorders (9.2%). Conclusions Over the past 10 years, all pediatric burn patients met ABA Burn Centre Referral Criteria based on TBSA, burn depth and burn location alone. This study is limited in that we were not able to capture all pediatric burn patients to identify those that warranted a referral but were not transferred. Applicability of Research to Practice The results indicate that burn-related transfers to the provincial burn centre were appropriate. The dissemination of this information to the referring centres may serve to reinforce these positive referral patterns. Furthermore, this audit provides insight into the geographic origins of pediatric burn referrals in the province to help direct burn prevention and physician education efforts, as well as resources for initial burn care and post-discharge rehabilitation services.

scholarly journals The Medical Social Worker: A Neglected Ally in the Management of Patients with Burn Injuries

2020 ◽  
Vol 17 (3) ◽  
Author(s):  
Kolawole Olubunmi Ogundipe ◽  
Innih Kadiri ◽  
Amarachukwu Chiduziem Etonyeaku ◽  
Tolulope Aduloju
Keyword(s):  
Social Worker ◽  
Burn Injury ◽  
Community Support ◽  
Health Financing ◽  
Burn Injuries ◽  
Added Value ◽  
Burn Patients ◽  
Burn Care ◽  
Medical Social Worker

Burn injuries come with enormous challenges and devastation to the victims. The consequences get worse when multiple members of a family are involved. Social supports are necessary, especially where health financing is mainly through out-of-pocket expenditure. The use of Medical Social Workers (MSW) in burn care in our region is limited, and their roles are poorly or inadequately reported. This study appraises the role of MSW in the multidisciplinary management of burn patients. We report the management of an impoverished family of five who sustained varying degrees of burn injuries, and the role MSW played in their care. Beyond being a routine discharge planner, the MSW provided social support, psychotherapy and rallied community support, which translated to an improved outcome for the patients. Involving MSW in burn care provides great benefit to patients. Burn surgeons are therefore encouraged to use the added value of MSW on their teams. Keywords: Burn, Injury, Medical social worker, Healthcare financing

scholarly journals End of Life, Food, and Water: Ethical Standards of Care

2021 ◽  
pp. 261-271
Author(s):  
Stefano Eleuteri ◽  
Arianna Caruso ◽  
Ranjeev C. Pulle
Keyword(s):  
End Of Life ◽  
Tube Feeding ◽  
Oral Intake ◽  
Nutrition Therapy ◽  
Oral Feeding ◽  
Standards Of Care ◽  
Artificial Nutrition ◽  
Artificial Nutrition And Hydration ◽  
Substitute Decision Maker ◽  
Nutrition And Hydration

AbstractEnd-of-life care constitutes an important situation of extreme nutritional vulnerability for older adults. Feeding decisions in late-stage dementia often provoke moral and ethical questions for family members regarding whether or not to continue hand-feeding or opt for tube-feeding placement. Despite the knowledge that starvation and dehydration do not contribute to patient suffering at the end of life and in fact may contribute to a comfortable passage from life, the ethics of not providing artificial nutrition and hydration (ANH) continue to be hotly debated. However, in the past two decades, voluntary stopping of eating and drinking (VSED) has moved from a palliative option of last resort to being increasingly recognized as a valid means to intentionally hasten death for cognitively intact persons dealing with a serious illness. Across many settings globally, when oral intake is deemed unsafe, decisions to withhold oral feeding and to forgo artificial means of providing nutrition are deemed to be ethically and legally sanctioned when the decision is made by a capable patient or their legally recognized substitute decision-maker. Decision-making at the end of life involves knowledge of and consideration of the legal, ethical, cultural, religious, and personal values involved in the issue at hand. This chapter attempted to illustrate the unique complexities when considering nutrition therapy (by oral and artificial means) at the end of life.

750 Burn Injury in Our Region’s Indigenous Population

2020 ◽  
Vol 41 (Supplement_1) ◽  
pp. S208-S209
Author(s):  
Lindsay Wainwright ◽  
Tanis Quaife ◽  
Saul Magnusson ◽  
Sarvesh Logsetty
Keyword(s):  
Length Of Stay ◽  
Indigenous People ◽  
Indigenous Population ◽  
Burn Injuries ◽  
Indigenous Populations ◽  
Observation Data ◽  
Burn Patients ◽  
Unique Challenge ◽  
Burn Care ◽  
Burn Survivors

Abstract Introduction Our Indigenous population is disproportionately affected by injury resulting in significant morbidity and mortality. Burn injuries in this population have not yet been explored. Barriers to healthcare faced by Indigenous people differ from non-Indigenous people and understanding these differences is essential to providing culturally safe care. Our research seeks to understand the characteristics of burns in our Indigenous population and the personal experiences of Indigenous burn survivors. Our aim is to raise awareness about the specialized needs of this population and provide cultural understanding to inform in-hospital care and repatriation to home communities. Methods Data was collected from our regional burn unit to examine burn characteristics between Indigenous and non-Indigenous burn survivors. The combined adult and pediatric burn registries were examined. Between 2008–2018 there were 615 complete observation data sets. Observations were grouped by Indigenous status, age, and urban/rural. Summary tables were constructed and t-tests performed to examine differences in burn severity and length of stay between the groups of interest. Results Indigenous burn patients in our region are younger at the time of injury and while they have a similar TBSA, their length of stay is considerably longer. Conclusions Burn injuries in the Indigenous population account for 25% of all admissions. Despite a similar burn size their injuries result in significantly longer stays in hospital. This may be because Indigenous burn patients are more likely to live in rural/remote settings far from specialized burn care compared to non-Indigenous patients. The distance from definitive care may the reason for the longer length of stay. Being far from their home community while in hospital is a unique challenge in this population. Future plans are to gain a better understanding of Indigenous burn patients and their barriers to care by completing a qualitative narrative analysis on Indigenous burn survivor healthcare experiences. This information will inform burn patient care in hospital and repatriation to home communities. Applicability of Research to Practice Burns are prevalent in Indigenous populations and understanding their experiences supports culturally competent care. The distance from definitive care seems to increase length of stay independent of the size of burn. This research aims to better understand this population so that we may better serve Indigenous burn patients.

scholarly journals Reaching consensus on an analgesia protocol for paediatric burn patients in a resource-scarce South African community

2021 ◽  
Vol 63 (1) ◽  
Author(s):  
Shelley L. Wall ◽  
Nikki L. Allorto ◽  
Verusia Chetty
Keyword(s):  
Resource Limited Setting ◽  
Burn Injuries ◽  
Expert Consensus ◽  
Burn Patients ◽  
Middle Income ◽  
Burn Care ◽  
Modified Delphi ◽  
Resource Limited ◽  
Limited Setting ◽  
Low And Middle Income

Background: Despite the exceptional burden of burns in low- and middle-income countries (LMIC) and the importance of adequate analgesia in burn care, there is a lack of analgesia protocol developed in resource-scarce settings. This necessitates the development of an analgesia protocol applicable to the resource-scarce setting. This study presents the findings of a modified Delphi study aimed at achieving consensus by a panel of experts in the management of burn injuries from low- and middle-income settings across Africa.Methods: A two-round Delphi survey was conducted to achieve consensus on an analgesia protocol for paediatric burn patients for a resource-limited setting. The Delphi panel consisted of nine experts with experience in management of burn injuries in low-income settings.Results: Consensus was determined by an a priori threshold of 80% of agreement for a drug to be included in the analgesia protocol. There was a largely overarching agreement with regard to the background analgesia protocol and strong agreement regarding the use of an initial dose of ketamine and midazolam for procedural sedation.Conclusion: A modified Delphi method was used to obtain expert consensus for a recently adopted analgesia protocol for burn-injured children in a resource-limited setting, with experts in the management of burn injuries in low- and middle-income settings. The expert consensus leads to the rigour and robustness of the protocol. Delphi methods are exceptionally valuable in healthcare research and the aim of such studies is to find converging expert opinions.

scholarly journals Candidemia in pediatric burn patients: Risk factors and outcomes in a retrospective cohort study

2020 ◽  
Author(s):  
Behnam Sobouti ◽  
Mostafa Dahmardehei ◽  
Shahrzad Fallah ◽  
Majid Karrobi ◽  
Yaser Ghavami ◽  
...  
Keyword(s):  
Risk Factors ◽  
Culture Media ◽  
Total Body Surface Area ◽  
Burn Injuries ◽  
Control Group ◽  
Burn Patients ◽  
Prevention Measures ◽  
Burn Care ◽  
Icu Stay ◽  
Mechanical Ventilation Duration

Background and Purpose: Despite advances in burn care and management, infections are still a major contributor to morbidity and mortality rates in patients with burn injuries. Regarding this, the present study was conducted to investigate the prevalence and importance of candidemia in pediatric burn patients. Materials and Methods: Blood samples were collected from the patients and cultured in an automated blood culture system. Candida species were identified using specific culture media. The relationship between candidemia and possible risk factors was evaluated and compared to a control group. Results: A total of 71 patients with the mean age of 4.52±3.63 years were included in the study. Blood cultures showed candidemia in 19 (27%) patients. Based on the results, C. albicans was the most common fungus among patients with and without candidemia. The results of statistical analysis also showed that candidemia was significantly correlated with total body surface area (TBSA), mechanical ventilation, duration of total parenteral nutrition, length of intensive care unit (ICU) stay, presence of neutropenia, and R-Baux score (all P≤0.001). In this regard, TBSA, length of ICU stay, R-Baux score, and Candida score were identified as the determinant factors for mortality due to candidemia. Conclusion: Candidemia increases the mortality and morbidity rates associated with burn injuries. Prompt diagnostic and prevention measures can reduce the unfortunate outcomes via controlling the possible risk factors. 

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