CLINICAL ARTICLES

Energy Expenditure in Burns: Lets Measure Something Else

In the 1970s, Long, Wilmore, and others documented progressive increases in caloric expenditure and nitrogen breakdown after acute burn injury, increases reaching a maximum of as much as 200% of normal expenditures by 10 to 14 days after burn before declining gradually.1,2 This accelerated use could cause lethal inanition within just a few weeks unless patients are fed supranormal diets to match their energy needs.3,4 To address these needs, a host of nutritional regimens were created; the most famous of these was the Curreri formula,5 which used data from only nine patients to back calculate the calories theoretically required to prevent observed weight loss. By the mid-1980s, practical devices for the bedside determination of energy use by indirect calorimetry were available. Studies in burn patients confirmed earlier descriptions of burn hypermetabolism and demonstrated both the inadequacy of formulas like Curreris in providing for the rapidly changing needs of burn patients and the tendency of many formulas to overestimate energy consumption.6,7 Thus, for at least 20 years, burn professionals have known how to measure and satisfy the dynamic and critical nutritional requirements of burn injury. However, research in this area has advanced little beyond these initial discoveries. In this months issue of the Journal, Liusuwan et al8 from Sacramento compared measured energy expenditure in burned children to a number of standardized formulas. They found onethe World Health Organization formula for basal energy expenditure, multiplied by a factor of 2.0 which correlated reasonably well. They conclude that a large study is needed to improve the prediction of energy needs in burned children. Unhappily, this study documents an industry-wide tendency to revisit the same well-traveled ground instead of addressing other questions we have largely ignored. For far too long, we have sought an elusive, all-encompassing formula that will allow us to feed our patients accurately when we know that no static formula can ever account for the tremendous variations over time and between individuals that have been repeatedly shown to occur. Liusuwan et als data consist of indirect calorimetry measurements obtained in just 10 children of varying ages, weights, and burn sizes. The data points are too few and too scattered to permit much confidence regarding their correlations. They give no data on the variations observed for individual patients, but we know that such serial measurements often vary greatly,
Copyright 2005 by the American Burn Association. 0273-8481/2005

each with different relationships to static formulas. Even if they had hundreds of data points, the best equation imaginable could never do more than predict average energy requirements and may not even do that. However, that criticism is confounded by another unanswered question: how close is close enough in attempting to meet nutritional needs? Normal human diets consist of intermittent meals followed by periods of fasting, which is entirely effective despite the fact that hour-by-hour or even day-to-day matching is poor. Critically ill patients have trouble tolerating such bolus feedings; however, even when nutrition is given continuously, how closely must it equal requirements? Liusuwan et als patients appear to have been adequately nourished, although the group doesnt tell us how often they achieved their goal of feeding within 10% of measured energy needs. Even this relatively imprecise goal may be optimistic, considering the host of complicating factorsincluding calorie-containing intravenous fluid; interruptions for surgery and therapy; fluctuations in energy associated with activity, fever, and ventilatory support, nausea, diarrhea, and otherswhich limit our ability to feed critically ill patients precisely. We have previously shown that indirect calorimetry-based feedings in fact did no better than standard formulas in actually nourishing a group of patients, for many of these reasons.9 For the same reason, it may be impossible to prove the superiority of one formula over another in practical application. It is simply too hard too hit the bulls eye every day. Finally, our ultimate goals for nutritional support also are poorly defined. The patients from Liusuwan et als study achieved positive nitrogen balance and acceptable weight maintenance during their treatment. Are these the most appropriate end points? In particular, the maintenance of body weight in immobilized, acutely stressed individuals almost has to mean some increase in total body water, fat, or both, and some decrease in muscle mass, no matter what nutritional regimen is used.10,11 Liusuwan et als patients restored visceral proteins and survived, both probably more meaningful measures of successful nutrition, although it certainly doesnt mean that patients may not have been overfed or underfed to some degree. We simply do not know how else to measure success. Liusuwan et al are to be congratulated for trying to find a rational and consistent way to nourish patients. However, for all the reasons listed here, future studies will need to do more. We should begin now to design multicenter randomized trials to compare nutritional formulas by actually using them to feed significant numbers of patients and to measure

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more detailed outcomes of treatment, including visceral proteins, length of stay, and functional recoveries. In this way, we may finally be able to move beyond repeatedly attempting to predict what ought to work. REFERENCES
1. Wilmore D, Long J, Mason, A, et al. Catecholamines: mediators of the hypermetabolic response to thermal injury. Ann Surg 1974;180:6538. 2. Long C, Schaffel N, Geiger C, et al. Metabolic response to injury and illness: estimation of energy and protein needs from indirect calorimetry and nitrogen balance. JPEN J Parenter Enteral Nutr 1979;3:4526. 3. Newsome T, Mason A, Pruitt B. Weight loss following thermal injury. Ann Surg 1973;178:2157. 4. Gump F, Kinney J. Energy balance and weight loss in burned patients. Arch Surg 1971;103:4428. 5. Curreri P, Richmond D, Marvin J, Baxter C. Dietary requirements of patients with major burns. J Am Diet Assoc 1974; 65:4157. 6. Ireton D, Turner W, Hunt, J, et al. Evaluation of energy expenditures in burn patients. J Am Diet Assoc 1986;86: 3313.

7. Saffle J, Medina E, Raymond J, et al. Use of indirect calorimetry in the nutritional management of burn patients. J Trauma 1985;25:329. 8. Liusuwan RA, Palmieri TL, Kinoshita L, Greenhalgh DG. Comparison of measured resting energy expenditure versus predictive equations in pediatric burns. J Burn Care Rehabil 2005;26:XXXXXX . 9. Saffle J, Larson C, Sullivan J. A randomized trial of indirect calorimetry-based feedings in thermal injury. J Trauma 1990; 30:77684. 10. Streat S, Beddoe A, Hill G. Aggressive nutritional support does not prevent protein loss despite fat gain in septic intensive care patients. J Trauma 1987;27:2626. 11. Zdolsek J, Lindahl O, Augquist K, Sjoberg F. non-invasive assessment of innercompartmental fluid shifts in burn victims. Burns 1998;24:23340.

Jeffrey R. Saffle, MD University of Utah Health Center Salt Lake City, Utah
DOI: 10.1097/01.bcr.0000185412.93979.f9 (Article begins on page 464)