A 26-year-old man in the burn unit is being evaluated for nutritional needs. The patient was admitted 12 hours ago after the trash he was burning exploded, causing partial- and full-thickness burns to the face, the anterior chest and abdomen, and both upper extremities. He has been receiving IV crystalloid resuscitation titrated to an adequate urine output, and his burns have undergone initial debridement and dressing with topical antimicrobial ointment. Temperature is 37.6 C (99.7 F), blood pressure is 132/86 mm Hg, and pulse is 100/min. The patient is mildly sedated but arousable. Burn dressings are intact, with some serous drainage, and the abdomen is soft and nondistended. Which of the following is the most appropriate management of this patient's nutrition?

Question

A 26-year-old man in the burn unit is being evaluated for nutritional needs.  The patient was admitted 12 hours ago after the trash he was burning exploded, causing partial- and full-thickness burns to the face, the anterior chest and abdomen, and both upper extremities.  He has been receiving IV crystalloid resuscitation titrated to an adequate urine output, and his burns have undergone initial debridement and dressing with topical antimicrobial ointment.  Temperature is 37.6 C (99.7 F), blood pressure is 132/86 mm Hg, and pulse is 100/min.  The patient is mildly sedated but arousable.  Burn dressings are intact, with some serous drainage, and the abdomen is soft and nondistended.  Which of the following is the most appropriate management of this patient's nutrition?

Quizplus · Accepted Answer

Explanation: Like other trauma patients, patients with moderate to severe burn injuries often develop a hypermetabolic response characterized by increased energy expenditure and protein catabolism. In such patients, early nutritional support can both offset hypermetabolism and improve overall outcomes. Enteral nutrition (EN) (ie, via the intestinal route) is preferred over parental (ie, intravenous) nutrition in patients with burn injuries because EN is associated with multiple clinical benefits, including the following: Trophic effects on the intestinal mucosa and the gut- and mucosa-associated lymphoid tissue, resulting in maintenance of gut integrity and decreased bacterial translocation Reduced rates of sepsis and other infectious complications (eg, pneumonia) Decreased mortality EN (eg, via feeding tube) is ideally initiated within 24 hours of the burn injury, beginning at a low rate (ie, trickle feeding) that is progressively increased as tolerated by the patient. EN formulas can be tailored to provide various amounts of carbohydrates (both simple and complex), protein, fatty acids, vitamins, minerals, and electrolytes. Given the increased protein catabolism in patients with moderate to severe burns, high-protein, high-calorie formulas are typically used. (Choice A) Administration of dextrose-containing fluids would provide a small number of calories but lack additional nutrients (eg, protein). In addition, it would not provide the benefits (eg, maintenance of gut integrity) associated with EN. (Choice B) Given the benefits (eg, maintenance of gut integrity) of early EN, tube feeds are ideally initiated within 24 hours of the burn injury; the main indication for delay is hemodynamic instability (due to potentially inadequate perfusion of the gastrointestinal tract), which is not present in this patient. (Choices D and E) Total parenteral nutrition (TPN) is typically administered via a central venous catheter and can provide a complete but more elemental nutrient mixture. However, unlike EN, TPN does not promote gut integrity and is associated with liver dysfunction and increased mortality in burn patients. In addition, the use of a central venous catheter carries the risk of mechanical and infectious complications. TPN is typically used only for burn patients who show persistent intolerance to EN or whose nutritional intake is inadequate on maximal EN (eg, due to profound hypermetabolism). Educational objective: Enteral nutrition is the optimal form of nutrition for patients with moderate to severe burn injuries. Early initiation helps offset the hypermetabolic response present after burn injury and has multiple clinical benefits (eg, maintenance of gut integrity, reduced rate of sepsis, decreased mortality). References: Nutrition and metabolism in burn patients. (http://www.ncbi.nlm.nih.gov/pubmed/28428966) Early enteral nutrition for burn injury. (http://www.ncbi.nlm.nih.gov/pubmed/24761346)

A 26-Year-Old Man in the Burn Unit Is Being Evaluated