Elsevier

Clinical Nutrition

Volume 32, Issue 4, August 2013, Pages 497-502
Clinical Nutrition

ESPEN endorsed recommendations: Nutritional therapy in major burns

https://doi.org/10.1016/j.clnu.2013.02.012Get rights and content

Summary

Background & aims

Nutrition therapy is a cornerstone of burn care from the early resuscitation phase until the end of rehabilitation. While several aspects of nutrition therapy are similar in major burns and other critical care conditions, the patho-physiology of burn injury with its major endocrine, inflammatory, metabolic and immune alterations requires some specific nutritional interventions. The present text developed by the French speaking societies, is updated to provide evidenced-based recommendations for clinical practice.

Methods

A group of burn specialists used the GRADE methodology (Grade of Recommendation, Assessment, Development and Evaluation) to evaluate human burn clinical trials between 1979 and 2011. The resulting recommendations, strong suggestions or suggestions were then rated by the non-burn specialized experts according to their agreement (strong, moderate or weak).

Results

Eight major recommendations were made. Strong recommendations were made regarding, 1) early enteral feeding, 2) the elevated protein requirements (1.5–2 g/kg in adults, 3 g/kg in children), 3) the limitation of glucose delivery to a maximum of 55% of energy and 5 mg/kg/h associated with moderate blood glucose (target ≤ 8 mmol/l) control by means of continuous infusion, 4) to associated trace element and vitamin substitution early on, and 5) to use non-nutritional strategies to attenuate hypermetabolism by pharmacological (propranolol, oxandrolone) and physical tools (early surgery and thermo-neutral room) during the first weeks after injury. Suggestion were made in absence of indirect calorimetry, to use of the Toronto equation (Schoffield in children) for energy requirement determination (risk of overfeeding), and to maintain fat administration ≤ 30% of total energy delivery.

Conclusion

The nutritional therapy in major burns has evidence-based specificities that contribute to improve clinical outcome.

Introduction

Severe burn injuries remain a major health care problem through the World. There are good news though: the first is that the vast majority of injuries are small “bagatelle” injuries that can be treated as outpatient, with a little less than 10% of the victims requiring hospital admission, and only a few requiring intensive care (ICU) treatment1, 2; the second is that burn care has improved tremendously over the last 3 decades, resulting in a reduction of both mortality and of sequelae. Major burn injuries, i.e. those affecting more than 20% total burn surface area (TBSA) with or without inhalation injury, represent a specific condition when compared to the general intensive care pathologies. Critically ill burned patients are characterized by a strong oxidative stress, an intense inflammatory response, and a prolonged months-long hypermetabolic and catabolic response, all of which are proportional to the severity of injury (depth and extent). Nutrition therapy constitutes an integral part of the treatment, from the early start of the initial resuscitation.

The body of literature concerning burns' nutrition has increased over the 3 last decades, while some important trials should be completed during 2013. The American Burn Association (ABA) published guidelines for the management of burn injuries in 2001,3 based on a Medline search including years 1966 through 1998. As many aspects of management have evolved since that date, and particularly those concerning energy requirements, the French speaking societies included a revision of nutritional therapy in major burns in their upcoming global nutrition guidelines.

Section snippets

Material and methods

Experts in charge of burns' nutrition were nominated based on their experience by delegates of three scientific societies: Société Française d’Anesthésie-Réanimation (SFAR), Société de Réanimation de Langue Française (SRLF) and Société Francophone de Nutrition Clinique et Métabolisme (SFNEP).

Based on a PUBMED search including human studies 1979 through 2011, the experts produced a review of the literature and elaborated a French version of recommendations using the GRADE methodology (Grade of

Recommendations

Major burn patients are first of all critically ill. By default general ICU recommendations apply. Many high quality human studies, i.e. randomized and placebo controlled with reasonable number of patients, were published during the period, investigating major burn specific issues, enabling a reasonable GRADE rating (Table 1).

Conclusion

Artificial nutrition of patient suffering major burns is a highly specific therapy. Early enteral feeding, started within the first 12 h after injury, is an integral part of initial resuscitation. Nutrient requirements are not constant over time but are generally substantially higher than those of other critically ill patients: weight based predictive formula are consequently inaccurate. In addition, trace elements deficiencies develop early on in the most severe burn patients because of the

Conflicts of interest

Authors have no conflict of interest to declare. There was no industrial sponsoring of the guideline process.

Acknowledgments

The experts worked under the presidency of the Professors Noel Cano (Human Nutrition Unit, INRA and Clermont University), Dominique Hurel (Intensive Care Unit, F. Quesnay Hospital, Mantes-La-Jolie), Jean-Yves Lefrant (Surgical Intensive Care Unit, University Hospital, Nîmes), Jean-Charles Preiser (Department of Intensive Care, Erasme University Hospital, Brussels), and Fabienne Tamion (Medical Intensive Care Unit, University Hospital, Rouen)

Three authors (AFR, MRL, MMB) contributed equally to

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