ESPEN endorsed recommendations: Nutritional therapy in major burns☆
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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Expert group of the Société Française d'Anesthésie-Réanimation (SFAR), Société Francophone de Nutrition Clinique (SFNEP), Société de Réanimation de langue Française (SRLF).