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-thickness burns to the face and neck and full-thickness burns to the anterior chest, abdomen, and both upper extremities. He has been receiving intravenous crystalloid resuscitation titrated to an adequate urine output, and the burns have undergone initial débridement 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?
Like other trauma patients, those 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 offset hypermetabolism and improve outcomes.
Enteral nutrition (EN) (ie, intestinal route) is preferred over parenteral (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 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
Arousable patients may be able to eat; if not, a flexible, small-bore nasogastric feeding tube (eg, Dobhoff tube) can be placed, even with facial burns. EN is ideally initiated within 24 hours of the burn, beginning at a low rate (ie, trickle feeding) that is progressively increased as the patient tolerates. EN formulas can be tailored to provide various amounts of carbohydrates (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) Dextrose-containing fluids provide a small number of calories but lack additional nutrients (eg, protein). In addition, they 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 initiation, EN is ideally begun within 24 hours of the 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, more elemental nutrient mixture. However, TPN does not promote gut integrity and is associated with liver dysfunction and increased mortality in burn patients. In addition, use of a central venous catheter carries the risk for mechanical and infectious complications. TPN is typically used only for 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 after burns and has multiple clinical benefits (eg, maintenance of gut integrity, reduced rate of sepsis, decreased mortality).