also may occur in the patient with thermal injury are
reasons why enteral (vs. oral) nutrition is used; the
stomach may be bypassed, and the feeding tube is
placed in the upper part of the small intestine.
0011 The skin is the primary barrier for the body against
the external environment. When it is lost, as in the
severely burned patient, body tissues become exposed
to the environment, which contains a variety of bac-
teria and viruses. Current therapy includes a variety
of techniques and medications to prevent and treat
infection in the burn patient. None the less, a burn
patient frequently has cutaneous infections that may
pass into the blood, causing septicemia. The fever that
accompanies an infection increases energy needs, and
septicemia also produces a hypermetabolic state.
Metabolic rate is estimated to increase about 10%
for each 1
C increase in body temperature. Nutrient
requirements need to be reevaluated in the burn
patient when an infection ensues.
0012 A thermally injured patient may have one or more
preexisting diseases that affect the overall diet pattern
(Table 2). Consideration should be given to lowering
dietary fat if the patient has significant cardiovascular
disease, and sodium if chronic severe hypertension is
present. Obesity complicates the determination of
adequate energy intakes, as well as wound closure
and healing in the burn patient. During the hyper-
metabolic phase, protein becomes a primary substrate
for energy; there is little value in providing a hypo-
caloric diet during this phase, as the obese patient will
metabolize body protein if adequate amounts are not
provided. When normal metabolic pathways resume,
consideration can be given to a modest (10–25%)
reduction in estimated energy needs when the burn
patient is obese. Careful and continual coordination
of insulin availability, blood glucose concentrations,
and food intake is needed in the burn patient who also
has type 1 diabetes mellitus, the form of the disease in
which the body does not produce insulin. Similar
monitoring is also needed for the person with type 2
diabetes, in whom insulin response to food intake is
not normal, but monitoring is less frequent. Extra
care also is needed if the patient with diabetes is
given a very high (more than 55–60% of kilocalories)
carbohydrate diet.
0013 Many of the problems associated with tube feed-
ings can be avoided by the experienced clinician. If
the infusion rate is too fast and administration of the
feeding too frequent, there can be potential problems,
particularly for burn patients, for the simple reason
that they have to be given more in order to meet their
nutrient needs. Gastrointestinal stress that usually
occurs in the burn patient is manifest as a poor empty-
ing of the stomach; thus, ‘residuals,’ or the amount of
feeding remaining 2 h after its administration, need to
be determined frequently if the feeding tube is placed
in the stomach. It is also important to keep the head
of the patient elevated (at least a 30
angle) to prevent
aspiration, which is the movement of gastric contents
toward the mouth and subsequent entrance into the
trachea and ultimately the lungs.
0014Since the feeding tube may be in place for a long
period of time, smaller-diameter tubes are used,
because they are less irritating. These smaller-bore
tubes, however, cause mechanical problems, because
they become more easily clogged. Clogged tubes are
prevented by a rigorous maintenance protocol and by
not administering ground, solid medications through
the tube.
0015Gastrointestinal complications of tube feedings
include nausea and vomiting, diarrhea, constipation,
and abdominal cramping or pain, all of which also
can be caused by the injury and by medications unre-
lated to nutrient intake. Many of the gastrointestinal
problems can be prevented by maintaining constant
administration of the feeding with a pump. Nausea,
vomiting, and abdominal cramping may be a result of
retention of food in the stomach; if this does not
resolve spontaneously within a couple of days, the
tube can be repositioned so that food is delivered to
the gastrointestinal tract beyond the stomach. Diar-
rhea can be caused by gastrointestinal dysfunction,
too rapid a rate of administration, and bacterial
infection in the gut.
Metabolic Modulators
0016Several new therapies have been proposed to counter-
act the catabolism and hypermetabolism that accom-
pany a burn injury. However, many of the studies to
evaluate these new therapies have been very limited in
scope or conducted using animal models or critically
ill patients who were not burned. This is an active
area of research, but data available at this time do not
support the use of most of these therapies. Growth
hormone administration does not appear to benefit
the burn patient. Very high doses of insulin appear to
reduce protein losses, but such doses have not been
well accepted by burn centers, as they require
frequent blood glucose monitoring. Arginine and
glutamine are viewed as conditionally essential
amino acids, that is they are indispensible in situ-
ations of severe metabolic stress when body synthesis
may be inadequate. No convincing evidence exists
that they are of benefit specifically in the burn patient,
although they are included in some protocols, on the
basis that they may help and are unlikely to hamper
recovery.
0017The use of a particular group of enteral feedings,
called immune-enhancing therapies, for the burn
716 BURNS PATIENTS – NUTRITIONAL MANAGEMENT