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FN 418/618: Medical Nutrition Therapy II Spring 2017

Nutrition Support for Burn Injury Case Study


Dakota Cossairt

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Need to assess his current TF rate as this is his current nutritional intake. If you don't do this then how are y
nutritional needs are being met or not?

Need to include that he is currently receiving propofol as this provides significant kcals to him.

Also need to include how much protein the patient will receive from the goal rate of tube feeding.

A Mr. Angelo is a 65 yo male presented as level 1 trauma with 40% total


body surface area burns. ENT service performed a
nasopharyngolaryngoscopy. Patient is subject to a bronchoscopy. Physical
findings include laryngeal edema and soot on the vocal cords bilaterally.
Medical history includes diabetes, HTN, and GERD. Lab values indicate
elevated levels of CRP and decreased levels of protein, albumin, and pre-
albumin. Stable weight for past 6 months. Patient is on ventilator. MD
assessment included hyperkalemia, protein-calorie malnutrition, acute
kidney injury, oliguria, and respiratory failure. Patient was started on fluid
resuscitation per Parkland formula using Lactated Ringers @ 610 mL/hr.

Ht. = 72 Wt. = 156.6# IBW= 178# %IBW= 88% BMI =


21.3

Recommended kcals = 2600-2700 kcals/day (Ireton-Jones Equation)

Protein Requirements = 107-142 g/day (1.5-2.0 g/kg)

Fluid Requirements = 2000-2200 cc/day

Nutrition order = NPO with TF Impact with Glutamine @ 60 mL/hr

D Increased nutrient needs R/T increased energy expenditure and protein


loss AEB protein-calorie malnutrition, decreased total protein, albumin and
pre-albumin levels, and burn trauma

I RD recommends patient continue TF with Impact with Glutamine.


Advance 20 mL/hr every 4 hours until goal rate of 85 cc/hr is achieved. This
will provide patient with 2,650 kcal/day. Introduce solid food when GI tract is
ready; advance as quickly as possible from liquids to solids.

ME RD will follow-up with patient daily to assess intake of nutritional


intake, input/output, and hydration status. Monitor weight, lab values. Assess
patients tolerance to nutritional support.

Understanding the Diagnosis and Pathophysiology


1. Describe how burn wounds are classified. Identify and describe
Mr. Angelos burn injuries.
a. Burn wounds are classified into 4 different categories.
i. 1st degree
1. Tissue layer = epidermis
2. Skin thickness = 0.01
nd
ii. 2 degree
1. Tissue layer = epidermis & dermis
2. Skin thickness = 0.02
iii. 3rd degree
1. Tissue layer = epidermis, dermis & subcutaneous
tissue
2. Skin thickness = 0.035
iv. 4th degree
1. Tissue layer = epidermis, dermis, subcutaneous
tissue & muscle
2. Skin thickness = 0.04
b. Mr. Angelos burn injuries cover 40% of his total body surface
area. The burns involve his entire face. He has partial thickness
burns over his lower back and buttocks. There are partial
thickness and 1st degree burns near his umbilicus. His genitalia
has blistering over the scrotum and head of his penis. There is
partial thickness burns to his bilateral upper extremities and full
thickness circumferential burns to his lower extremities. Overall,
his skin condition is weeping, sloughing, blistering, and there is
necrosis.
2. Explain the rule of nines used in assessment of burn injury.
a. The rule of nines assesses the % of burn on the total body
surface area.
i. Head/neck - 9% TBSA
ii. Each arm - 9% TBSA
iii. Anterior thorax - 18% TBSA
iv. Posterior thorax - 18% TBSA
v. Each leg - 18% TBSA
vi. Perineum - 1% TBSA
3. Mr. Angelos fluid resuscitation order was: LR @ 610 mL/hr X
first 8 hours and decrease to 305 mL/hr X 16 hours. What is the
primary goal of fluid resuscitation? Briefly explain the Parkland
formula. What common intravenous fluid is used in burn
patients for fluid resuscitation? What are the components of
this solution?
a. Fluid Resuscitation
i. Primary goals
1. Achieve adequate tissue perfusion to prevent tissue
death
2. Maintain sufficient circulatory volume
b. Parkland Formula
i. Total fluid requirement in 24 hrs
ii. 4 mL X TBSA (%) X body weight (kg)
iii. 50% given in 1st 8 hours
iv. 50% given in next 16 hrs
v. Used to estimate needs for fluid resuscitation
vi. Calculated amount based on patients BW, age, and %TBSA
of the burn
c. Common intravenous fluids
i. Isotonic crystalloids
1. Most commonly used
2. Cheaper
3. Solution of sterile water w/ added electrolytes
4. Normal saline and Lactated Ringers (LR)
ii. Hypertonic solutions
1. Contain more sodium
2. Resuscitate patients using lower total fluid volume
iii. Colloids
1. Prove protein in solution
2. Protein leakage
5. Burns are often described as one of the most metabolically
stressful injuries. Discuss the effects of a burn on metabolism
and how this will affect nutritional requirements.
a. Hyper-metabolism
b. Energy needs usually increase 20-30%
c. Increased fluid needs
d. Specific vitamin and mineral supplementation is encouraged
e. Caloric goals can become 2xREE, but should not exceed that
f. Protein
i. Increased protein use in would healing and
gluconeogenesis
ii. Protein catabolism
iii. Protein should be 20-25% of total kcals
g. Increased urinary excretion
i. Increased nitrogen losses in urine
h. Weight loss is common
i. Lack of caloric intake
ii. Should not lose >10% UBW during healing process
i. Wound healing can only occur in anabolic state

6. List all medications that Mr. Angelo is receiving. Identify the


action of each medication and any drug-nutrient interactions
that you should monitor.

Medication Dosage Action Drug-Nutrient


Interactions
500 mg
iron absorption Iron
Ascorbic Acid every 12 Vitamin Antiscorbutic
toxicity
hrs
0.12% oral
solution 15 Disinfectant & topical anti- n/a
Chlorhexidine
mL every infective agent
12 hrs
20 mg Histamine H2-receptor
Famotidine Tablet every 12 antagonist inhibition of Hepatic function
hrs gastric secretion
5,000 units
Heparin Injections every 8 Anticoagulant Blood & potassium
hrs
Regular
injection Peptide hormone Glucose, CHO intake,
Insulin
every 6 improves glycemic control urine ketones
hrs
Multivitamin Tablet 1 Tab daily Vitamin n/a
Zinc Sulfate 220 mg Treat or prevent low levels Give hour before or 2 hrs
daily of zinc mineral after tube feeding
supplement
5 mg
Methadone every 8 Opioid Analgesic Narcotic Avoid grapefruit
hrs
Anabolic effect, need to
10 mg Synthetic hormone
meet required energy
Oxandrolone every 12 anabolic steroid promote
intake & protein. Assess
hrs weight gain
glucose
Laxative simulant treat
8.6 mg Electrolyte balance, fiber
Senna Tablet constipation & empty large
daily and fluid intake
intestine before surgery
100 mg
Electrolyte balance, fiber
Docusate Oral Liquid every 12 Laxative stool softener
and fluid intake
hrs
1% cream
topical Topical antimicrobial
Silver Sulfadiazine n/a
application activity
daily
650 mg
oral every Analgesic & antipyretic
Acetaminophen Allergic rxns
4 hrs as effects
needed
100 mg in
sodium
chloride Hypotonic-sedative drug
Midazolam HCI Avoid grapefruit, herbal
0.9% 100 anxiolytic & amnestic
(Versed) sedatives & stimulants
mL IV properties sedation
infusion (1
mg/hr)
0.5-1 mg
Hydromorphone IV every 3 Opioid analgesic relief of
Asses hydration status
(Dilaudid) Injection hrs as pain narcotic
needed
50-100
mcg IV Narcotic analgesic mu-
Fentanyl (Sublimaze) Fluid status & electrolyte
every 15 opioid agonist adjunct to
Injection balance for dehydration
min as anesthetics
needed
10 mg/mL
premix
infusion Anaesthetic agent
Propofol (Diprivan) (25 induction and/or Triglycerides & lipid panel
mcg/kg/mi maintenance of anesthesia
n IV
continuous
Thiamin 100 mg X Vitamin Vitamin B Increase CHO intake
antioxidant
erythropoietic cognition
and mood modulatory
3 days antiatherosclerotic
putative ergogenic
detoxification
antiberiberi
1 mg X 3 Vitamin Vitamin B Inhibited by vitamin C,
Folate
days antianemic B12 and iron
Understanding the Nutrition Therapy
7. Using evidence-based guidelines, describe the potential
benefits of early enteral nutrition in burn patients.
a. Benefits of early enteral nutrition include reduced disease
severity, decreased length of time in the ICU and decreased
infectious morbidity and decreased mortality.
8. What are the common criteria used to assess readiness for the
initiation of enteral nutrition in burn patients?
a. The first step in assessing a patients readiness for initiation of
enteral nutrition is to establish their hemodynamic stability. To
establish this, the patients heart rate, blood pressure, cardiac
output, oxygen, and mean arterial pressure saturation should be
assessed.
b. A patient should not receive EN until they are fully resuscitated
and/or stable
9. What are the specialized nutrient recommendations for the
enteral nutrition formula administered to burn and trauma
patients per ASPEN/SCCM guidelines?
a. Glutamine should be added to standard enteral formula in
burned patients
b. 10.4 Burns: Trace elements (Cu, Se and Zn) should be
supplemented in a higher than standard dose.
c. ASPEN Guideline F1. Based on expert consensus, we suggest
that a fermentable soluble fiber additive be considered for
routine use in all hemodynamically stable medical and surgical
ICU patients placed on a standard enteral formulation. We
suggest that 1020 grams of a fermentable soluble fiber
supplement be given in divided doses over 24 hours as
adjunctive therapy if there is evidence of diarrhea.
d. ASPEN Guideline F3. We suggest that a combination of
antioxidant vitamins and trace minerals in doses reported to be
safe in critically ill patients be provided to those patients who
require specialized nutrition therapy
e. ASPEN Guideline F4: The addition of enteral glutamine to an
EN regimen (not already containing supplemental glutamine)
should be considered in burn, trauma, and mixed ICU patients
f. No general amount can be recommended as EN therapy has to
be adjusted according to the progression/course of the disease
and to gut tolerance. During the acute and initial phase of critical
illness an exogenous energy supply in excess of 2025 kcal/kg
BW/day may be associated with a less favorable outcome (C).
During recovery (anabolic flow phase), the aim should be to
provide 2530 total kcal/kg BW/day (C).
Source: http://espen.info/documents/enicu.pdf &
http://journals.sagepub.com/doi/pdf/10.1177/0148607115621863 &
http://www.criticalcarenutrition.com/docs/BOB/BeaumontGuidelines.
pdf
10. What additional micronutrients will need
supplementation in burn therapy? What dosages are
recommended?
a. Glutamine
i. 0.3-0.5 g/kg/day for 10-g doses via feeding tube 2-4 X daily
b. Zinc
i. 20% TBA full thickness OR 30% TBSA
ii. 30 mg elemental/day intravenously X 5 days
AND THEN
iii. 50 mg elemental zinc daily by mouth or feeding tube
c. Selenium
i. 20% TBA full thickness and intubated OR 30% TBSA
ii. 1000 g/day parenterally X 14 days
AND THEN
iii. 200 g twice daily by mouth or feeding tube
d. Vitamin C
i. 20% TBA full thickness OR 30% TBSA
ii. 500 mg/day 2x/day by mouth or feeding tube
e. Vitamin E
i. 400 units 2x/day by mouth or feeding tube
Nutrition Assessment
11. Using Mr. Angelos height and admit weight, calculate
IBW, %IBW, BMI, and BSA.
IBW = 178#
106# + (6# * 12) = 178#
%IBW = 88%
(156.6# / 178#) * 100 = 88%
BMI = 21.3 kg/m2
71.2kg/3.345m2 = 21.3
BSA = 1.902 m2
(182.88cm * 71.2kg) / 3600 = 3.61696 3.61696 = 1.902 m2
12. Energy requirements can be estimated using a variety of
equations. The Xie and Zawacki equations are frequently used.
Estimate Mr. Angelos energy needs using these equations.
How many kcal/kg does he require based on these equations?
Ht. = 72 182.88 cm 1.823 m 3.3489 m2
Wt. = 156.6# 71.2 kg
EEE = 1784 11(65) + 5(71.2) + 244(1) + 239(1) + 804(1) = 2712 kcal
2700 kcals/day
13. Determine Mr. Angelos protein requirements. Provide the
rationale for you estimate.
Protein Requirements = 107-142 g/day (1.5-2.0 g/kg)
1.5g * 71.2kg = 106.8 g protein
2.0g * 71.2kg = 142.4 g protein
Recommend 1.5-2.0 because the patient is a burn victim and they have
increased protein needs for wound healing.
14. The MDs progress note indicates that the patient is
experiencing acute kidney injury. What is this? If the patients
renal function continues to deteriorate and he needs
continuous renal replacement therapy, what changes will you
make to your current nutritional regimen and why?
a. Acute Kidney Injury
i. A sudden episode of kidney failure or kidney damage,
which happens within a few hours or a few days.
ii. It causes build-up of waste products in the blood
iii. Makes it hard for the kidneys to keep the right balance of
fluids in the body
iv. Also affects other organs like the brain, heart, and lungs
Source: https://www.kidney.org/atoz/content/AcuteKidneyInjury
Nutrition Diagnosis
16. Identify at least 2 of the most pertinent nutrition
problems and the corresponding nutrition diagnoses.
a. Increased protein needs for wound healing
b. Increased fluid needs
c. Malnutrition
17. Write a PES statement for each nutrition problem.
a. Increased nutrient needs R/T increased energy expenditure and
protein loss AEB protein-calorie malnutrition, decreased total
protein, albumin and pre-albumin levels, and burn trauma
b. Inadequate fluid intake R/T increased fluid needs AEB oliguria,
poor skin turgor, and yellow urine color
Nutrition Intervention
18. The patient is receiving enteral feeding using Impact with
Glutamine @ 60 mL/hr. determine the energy and protein
provided by this prescription. Provide guidelines to meet the
patients calculated needs using the Xie equation.
a. Impact w/ Glutamine
i. Caloric Density = 1.3 kcal/mL
ii. Osmolarity
1. 630 mOsm/kg water
iii. Carbs 46% total kcal
iv. Protein = 24% total kcal
v. Lipid = 30% total kcal
Calories
60 mL/hr * 24 hr/day = 1440 mL/day or 1.44 L/day
1.3 kcal/mL * 60 mL/hr = 78 kcal/hr
1.3 kcal/mL * 1440 mL/day = 1872 kcal/day
Protein
78 g/L * 1.44 L = 112.32 g protein
112.32 g * 9g/kcal = 1,011 kcal from protein
19. By using the information on the intake/output record,
determine the energy and protein provided during this time
period. Compare the energy and protein provide by the enteral
feeding to your estimation of Mr. Angelos needs.
a. Input from enteral feeding = 565 mL/day
b. (565mL / 1440mL) * 100 = 39.2%
c. 1872 kcal * 39.2% = 734 total kcal currently
d. 1,011 kcal from protein * 39.2% = 396 kcal from protein
currently
e. Patient is only receiving 39.2% of his calculated energy needs.
He is currently only receiving 734 kcal/day and 396 kcal from
protein.
20. One of the residents on the medical team asks you if he
should stop the enteral feeding because the patients blood
pressure has been unstable. What recommendation can you
make to the patients critical care team regarding tube feeding
and hemodynamic status?
a. Fluctuating blood pressure (hypotension) is common in critically
ill patients and can be due to GI intolerance.
Nutrition Monitoring and Evaluation
21. List factors that you would monitor to asses the tolerance
to and adequacy of nutrition support.
a. Daily I/O of fluid
b. Weight
c. Nutritional intake
d. Lab values
e. Hydration status
f. Stool output/consistency
g. Distension and comfort in the abdomen
22. What is the best method to assess caloric needs in
critically ill patients? What are the factors that need to be
considered before the test is ordered?
a. Ireton-Jones for burn victims
b. 25-30 kcal/kg for non-obese patients
c. 14-18 kcal/kg of ABW
d. 22 kcal/kg of IBW