Early enteral nutrition in burns: compliance with guidelines and associated outcomes in a multicenter study.

Department of Surgery, Loyola University Medical Center, Maywood, Illinois 60153, USA.
Journal of burn care & research: official publication of the American Burn Association (Impact Factor: 1.55). 12/2010; 32(1):104-9. DOI: 10.1097/BCR.0b013e318204b3be
Source: PubMed

ABSTRACT Early nutritional support is an essential component of burn care to prevent ileus, stress ulceration, and the effects of hypermetabolism. The American Burn Association practice guidelines state that enteral feedings should be initiated as soon as practical. The authors sought to evaluate compliance with early enteral nutrition (EN) guidelines, associated complications, and hospitalization outcomes in a prospective multicenter observational study. They conducted a retrospective review of mechanically ventilated burn patients enrolled in the prospective observational multicenter study "Inflammation and the Host Response to Injury." Timing of initiation of tube feedings was recorded, with early EN defined as being started within 24 hours of admission. Univariate and multivariate analyses were performed to distinguish barriers to initiation of EN and the impact of early feeding on development of multiple organ dysfunction syndrome, infectious complications, days on mechanical ventilation, intensive care unit (ICU) length of stay, and survival. A total of 153 patients met study inclusion criteria. The cohort comprised 73% men, with a mean age of 41 ± 15 years and a mean %TBSA burn of 46 ± 18%. One hundred twenty-three patients (80%) began EN in the first 24 hours and 145 (95%) by 48 hours. Age, sex, inhalation injury, and full-thickness burn size were similar between those fed by 24 hours vs after 24 hours, except for higher mean Acute Physiology and Chronic Health Evaluation II scores (26 vs 23, P = .03) and smaller total burn size (44 vs 54% TBSA burn, P = .01) in those fed early. There was no significant difference in rates of hyperglycemia, abdominal compartment syndrome, or gastrointestinal bleeding between groups. Patients fed early had shorter ICU length of stay (adjusted hazard ratio 0.57, P = 0.03, 95% confidence interval 0.35-0.94) and reduced wound infection risk (adjusted odds ratio 0.28, P = 0.01, 95% confidence interval 0.10-0.76). The investigators have found early EN to be safe, with no increase in complications and a lower rate of wound infections and shorter ICU length of stay. Across institutions, there has been high compliance with early EN as part of the standard operating procedure in this prospective multicenter observational trial. The investigators advocate that initiation of EN by 24 hours be used as a formal recommendation in nutrition guidelines for severe burns, and that nutrition guidelines be actively disseminated to individual burn centers to permit a change in practice.

  • [Show abstract] [Hide abstract]
    ABSTRACT: Significance: Nutrition has been recognized as a critical component of acute burn care and ultimate wound healing. Debate remains over the appropriate timing of enteral nutrition and the benefit of supplemental trace elements, antioxidants, and immunonutrition for critically ill burn patients. Pharmacotherapy to blunt the metabolic response to burn injury plays a critical role in effective nutritional support. Recent Advances: Further evidence is demonstrating long-term benefits from pharmacologic immunomodulation given the prolonged metabolic response to injury that may last for over a year following the initial insult. Critical Issues: The majority of evidence regarding early enteral feeding comes from mixed populations and smaller studies. However, on balance, available evidence favors early feeding. Data regarding immunonutrition does not support the routine use of these products. Limited data regarding use of antioxidants and trace elements support their use. Future Directions: Further evaluation of anti-inflammatory mediators of the immune response, such as statins, will likely play a role in the future. Further data are needed on the dosing and route of micronutrients as well as the utility of immunonutrition. Finally, little is known about nutrition in the obese burn patient making this an important area for investigation.
    Advances in wound care. 01/2014; 3(1):64-70.
  • [Show abstract] [Hide abstract]
    ABSTRACT: Severe weight loss resulting from inadequate nutritional intake along with the hypermetabolism after thermal injury can result in impaired immune function and delayed wound healing. This observational study was conducted on adults admitted between October 2007 and April 2012 with at least 20% total body surface area burn requiring excision who previously tolerated gastric enteral nutrition at calorie goal and who returned from surgery hemodynamically stable (no new pressor requirement) and compared the effect of goal rate re-initiation versus slow re-initiation after the first excision and grafting. Demographic, intake, and tolerance data were collected during the 36h following surgery and were analyzed with descriptive and comparative statistics. Data were collected on 14 subjects who met the inclusion criteria. Subjects in the goal rate re-initiation group (n=7) met a significantly greater percentage of caloric goals (99±12% versus 58±21%, p=0.003) during the 36h following surgery than subjects in the slow re-initiation group (n=7). There were no incidences of emesis, aspiration, or ischemic bowel in either group. The goal rate re-initiation group had a 29% incidence of either stool output >1L (n=1) or gastric residual volumes >500mL (n=1), whereas these were not present in the slow re-initiation group (p=0.462). In conclusion, in this small pilot study, we found that enteral nutrition could be re-initiated after the first excision and grafting in those patients who previously tolerated gastric enteral nutrition meeting caloric goals who return from surgery hemodynamically stable without a significant difference in intolerance and with a significantly higher percentage of calorie goals achieved, but larger studies are required.
    Burns: journal of the International Society for Burn Injuries 07/2014; · 1.95 Impact Factor
  • [Show abstract] [Hide abstract]
    ABSTRACT: Intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are complications that may occur in severely burned patients. Evidenced based medicine for these patients is in its early development. The aim of this study was to provide an overview of literature regarding IAH and ACS in severely burned patients. A systematic search was performed in Cochrane Central Register of Controlled Trials, PubMed, Embase, Web of Science and CINAHL on October 1, 2012. These databases were searched on 'burn', 'intra-abdominal hypertension', 'abdominal compartment syndrome', synonyms and abbreviations. Studies reporting original data on mortality, abdominal decompression or abdominal pressure related complications were included. Fifty publications met the criteria, reporting 1616 patients. The prevalence of ACS and IAH in severely burned patients is 4.1-16.6% and 64.7-74.5%, respectively. The mean mortality rate for ACS in burn patients is 74.8%. The use of plasma and hypertonic lactated resuscitation may prevent IAH or ACS. Despite colloids decrease resuscitation volume needs, no benefit in preventing IAH was proven. Escharotomy, peritoneal catheter drainage, and decompression laparotomy are effective intra-abdominal pressure (IAP) diminishing treatments in burn patients. Markers for IAP-related organ damage might be superior to IAP measurement itself. ACS and IAH are frequently seen devastating complications in already severely injured burn patients. Prevention is challenging but can be achieved by improving fluid resuscitation strategies. Surgical decompression measures are effective and often unavoidable. Timing is essential since decompression should prevent progression to ACS rather than limit its effects. Prognosis of ACS remains poor, but options for care improvement are available in literature.
    Burns: journal of the International Society for Burn Injuries 09/2013; · 1.95 Impact Factor


Available from
Jun 4, 2014

Similar Publications