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: 1.43). 12/2010; 32(1):104-9. DOI: 10.1097/BCR.0b013e318204b3be
Source: PubMed


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.

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    • "Recent studies in the paediatric burn population have shown a relationship between later initiation of enteral nutrition and a worsened prognosis [11]. Mosier et al. after a multicenter study found that patients fed early had shorter length of stay and wound infection risk [22]. It has also been shown that a lower fT3 level worsens the prognosis in adult burn patients [10]. "
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    ABSTRACT: Objective. The aim of this study was to determine if early initiation of oral/enteral nutrition in burn patients minimizes the drop in fT3 levels, reduces the potential for euthyroid sick syndrome (ESS), and shortens the length of hospital stay (LHS). Subjects and Methods. We retrospectively evaluated the statistical association of serum fT3, fT4, and TSH at the first (2nd-5th day) and second sample collection (9th-12th day) after the burn injury in 152 burn patients. Three groups were established depending on time of initiation of the oral/enteral nutrition: <24 h before the injury (Group 1), 24-48 h after the injury (Group 2), and >48 h after the injury (Group 3). Results. They were expressed as mean ± standard deviation. We found that LHS and the fT3 levels were statistically different in the 3 groups. The LHS (in days) was, respectively, in each group, 16.77 ± 4.56, 21.98 ± 4.86, and 26.06 ± 5.47. Despite the quantifiable drop in fT3, ESS was present only at the first sample collection (2.61 ± 0.92 days) in Group 3, but there was no group with ESS at the second sample collection (9.89 ± 1.01 days). Our data suggest that early initiation of nutritional supplementation decreases the length of hospitalization and is associated with decreasing fT3 serum concentration depression. Conclusion. Early initiation of oral/enteral nutrition counteracts ESS and improves the LHS in burn patients.
    Full-text · Article · Jan 2013 · International Journal of Endocrinology
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    • "The burned mice also exhibited a profound and prolonged period of increased food and water intake up to 80 days which is consistent with the increased nutritional requirements observed in severe burn patients who remain hypermetabolic with increased resting energy expenditure for up to 2 years following burn injury [4, 26] (Fig. 6). It has been shown repeatedly that a lack of increased nutritional support during this period reduces overall survival and recovery in severe burn patients [27]. Also, the mice exhibited a prolonged period of significant polydipsia out to 80 days, likely attributable acutely to the water and heat loss commonly found following burn (water loss can approach 4,000 mL/m2 burn area per day) and chronically due to a persistent hypermetabolic state [26]. "
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    ABSTRACT: Burn injury results in a chronic inflammatory, hypermetabolic, and hypercatabolic state persisting long after initial injury and wound healing. Burn survivors experience a profound and prolonged loss of lean body mass, fat mass, and bone mineral density, associated with significant morbidity and reduced quality of life. Understanding the mechanisms responsible is essential for developing therapies. A complete characterization of the pathophysiology of burn cachexia in a reproducible mouse model was lacking. Young adult (12-16 weeks of age) male C57BL/6J mice were given full thickness burns using heated brass plates or sham injury. Food and water intake, organ and muscle weights, and muscle fiber diameters were measured. Body composition was determined by Piximus. Plasma analyte levels were determined by bead array assay. Survival and weight loss were dependent upon burn size. The body weight nadir in burned mice was 14 days, at which time we observed reductions in total body mass, lean carcass mass, individual muscle weights, and muscle fiber cross-sectional area. Muscle loss was associated with increased expression of the muscle ubiquitin ligase, MuRF1. Burned mice also exhibited reduced fat mass and bone mineral density, concomitant with increased liver, spleen, and heart mass. Recovery of initial body weight occurred at 35 days; however, burned mice exhibited hyperphagia and polydipsia out to 80 days. Burned mice had significant increases in serum cytokine, chemokine, and acute phase proteins, consistent with findings in human burn subjects. This study describes a mouse model that largely mimics human pathophysiology following severe burn injury. These baseline data provide a framework for mouse-based pharmacological and genetic investigation of burn-injury-associated cachexia.
    Full-text · Article · Mar 2012
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    ABSTRACT: Burns commonly occur in children and their first aid remains inadequate despite burn prevention programmes. While scald injuries predominate, contact and flame burns remain common. Although typically less severe injuries overall than those in adults, hypertrophic scarring complicating both the burn wound and even donor sites occur more frequently in children. The heterogeneous nature of burn wounds, coupled with the difficulties associated with the early clinical assessment of burn depth, has stimulated the application of novel technologies to predict burn wound outcome. This review explores current best practice in the management of paediatric burns, with a focus on prevention, optimal first aid, resuscitation, burn wound prediction and wound management strategies.
    Full-text · Article · Jun 2011 · Journal of Paediatrics and Child Health
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