Burns

 

Best time to refer to the dietician:

• When at least one of the following conditions applies:

• burns covering 15% or more of the total body surface area. For children and people in poor general health (at-risk populations are the elderly (over age 60), alcoholics, drug addicts, and psychiatric patients), this percentage is 10% or more.
• third-degree burns covering more than 10% of the total body surface
• burns combined with mechanical ventilation
• burns and/or symptoms localized where they hinder food intake and/or absorption
• if there is a disturbance in food intake lasting more than two days and no improvement is expected.

 

Relevant information for the dietician:

• Diagnosis: magnitude, depth and localization of the burn wounds, any comorbidity
• Symptoms: edema, diarrhea, nausea, gastric retention, presence or absence of mechanical ventilation
• Medications: antibiotics, anti-diarrheal drugs, antiemetics, infusion fluids, laxatives
• Other: height, usual weight or weight during hospitalization, PBD (“post burn day”), minimum and maximum fluid requirements

 

Aims of the diet:

• maintain/improve nutritional status
• contribute to the healing of the burn wounds
• maintain/improve fluid, mineral and electrolyte balances
• prevent infections

 

Characteristics of the diet:

• Energy-enriched:

Adults

• Energy requirement (kcal) = (25 x (ideal) body weight (kg) + 40 x percentage burned Body Surface Area (BSA)

Children

• 0-1 year old: 2100 kcal/m²  total BSA + 1000 kcal/m² burned BSA
• 1-10 years old: 1800 kcal/m² total BSA + 1300 kcal/m² burned BSA
• > 10 years old: 1500 kcal/m² total BSA + 1500 kcal/m² burned BSA

• The formula for calculating body surface area is:

 

                                       (height (cm) x body weight (kg))

BSA (m²) = √       _____________________________

                                                             3600

 

• High-protein: protein should account for 20% of total caloric intake
• Increase fluid intake: The amount depends on the diuresis. After the shock phase, a rule of thumb before administering the daily fluid amount is: basal fluid requirement (see table) + the loss from evaporation as a result of the burn wounds (not measurable). A formula for the loss of evaporation is:

 

1.25 ml x percentage burn wounds x body weight in kg (in ml/day).

 

Age	Daily basal fluid requirements
Neonates (up to 72 hours after birth) Children up to 10 kg Children from 10-20 kg Children from 20-30 kg Adults The elderly	60-100 ml/kg 100 ml/kg 1000 ml/kg for the first 10 kg + 50 ml/kg for every kilogram over 10 kg 1500 ml/kg for the first 20 kg + 20 ml/kg for every kilogram over 20 kg at least 1500 ml at least 1700 ml

 

• In adults, the goal is 0.5 - 1 ml of urine output per kg body weight per hour. For children weighing up to 25 kg, the goal is 0.5-2.0 ml/kg/hour. Note: Bear in mind possible absorption and excretion of edema.
• High sodium: The amount depends on the losses and is measurable by checking the sodium levels in the blood and urine. To give an example: for an adult who is receiving primarily tube feeding, a supplement of 10 g NaCl is very common.
• Ensure adequate intake of vitamin C and zinc
• Immunonutrition: The requirements are increased for glutamine, arginine, copper, manganese, selenium and vitamin A, among others. The adequate and recommended amounts are not known. In the case of total parenteral nutrition, adding 25-35g glutamine is recommended.
• Low bacterial diet for major burn wounds (over 20% of body surface area).

 

Treatment time:

• Care level 3, see “Dietician’s working methods.”

 

In the specific phases:

The shock phase (the first 24-48 hours)

• Start with food and a dietary regimen in which the energy content is increased gradually over 3-5 days until the target amount is reached.

The acute or catabolic phase 

• This phase can take weeks to months, depending on the extent of the wounds and complications. Monitor intake and weight about twice a week, and if necessary, adjust the dietary regimen and anticipate complications. When the patient is stable and no further complications occur, the patient can be categorized into the next phase. The percentage of defects has often decreased to 15% or less by then, and the patient is no longer required to stay in the Intensive Care Unit.

The anabolic phase

• This phase may still take weeks. Rehabilitation starts during this phase, even though several surgeries may still be required to close the remaining wounds. Monitor intake about once a week and adjust it based on the reduced need for energy and nutrients. When the patient no longer has difficulty eating and drinking, and the wounds are minor, then dietary treatment may be discontinued.

 

Specific remarks:

• Edema may mask weight loss.
• It is recommended that dietetic treatment begin within 24 hours following the burn injury.
• Treatment of major burns requires specific knowledge and experience, which can be found in specialized burn units in Beverwijk (Rode Kruis Ziekenhuis), Groningen (Martini Ziekenhuis) and Rotterdam (Maasstad Ziekenhuis).

 

References:

Brand-Van Tilburg RF, Baljon RM et al. Brandwondenzorg - een multidisciplinaire

benadering. Maarssen: Elsevier gezondheidszorg; 2000

 

Stevens J, Beerthuizen GIJM. Voeding bij brandwonden. In: Geerts-Van der Weij ACW, Binsbergen JJ van, et al, editors. Informatorium voor Voeding en Diëtetiek. Houten/Diegem: Bohn Stafleu Van Loghum; 2008 p. Dieetleer XXa.1-Xxa.24

 

Valerio PG, Hurk TAM van den. Brandwonden. In: Taminiau JAJM, Meer K de, et al, editors. Werkboek enterale voeding bij kinderen. Amsterdam: VU Boekhandel / Uitgeverij BV.; 1997. p. 122-9

 

Burns was updated by Gretha Wesseling-Keuning, José van der Hulst and Yvonne Verweij-Tilleman, dieticians in the specialized burn centers in Groningen, Beverwijk and Rotterdam, respectively.