What are the guidelines for early nutritional support in burned patients?

Early Nutritional Support in Burn Patients

Nutritional support should be initiated within 12 hours after burn injury, preferring oral or enteral routes over parenteral nutrition. 1

Timing of Nutritional Support

Early enteral nutrition (EN) is a critical component of burn care management with significant benefits for patient outcomes:

• Initiate nutritional support within 12 hours after burn injury 1
• For severe burns, start feeding within the first 6-12 hours 1
• Some evidence supports even earlier initiation (within 4 hours) for improved outcomes 2

Early EN provides multiple physiological benefits:

• Attenuates neuro-hormonal stress response and hypermetabolic response 1
• Increases production of immunoglobulins 1
• Reduces incidence of stress ulcers 1
• Reduces risk of energy and protein deficiency 1
• Decreases wound infection risk 3
• Shortens ICU length of stay 3
• Reduces mortality in pediatric burn patients 4

Route of Administration

The route of nutritional support should follow this hierarchy:

1. Oral route (if patient can tolerate)
2. Enteral route (via feeding tube)
3. Parenteral route (only if enteral feeding is contraindicated or insufficient)

Enteral nutrition is preferred over parenteral nutrition when the gastrointestinal tract is functioning 1. For patients with burns and a viable GI tract (bowel length >75 cm), early EN is beneficial 1.

Nutritional Requirements

Energy Requirements

• Acute/initial phase: 20-25 kcal/kg BW/day 1, 5
• Recovery/anabolic phase: 25-30 kcal/kg BW/day 1, 5

Protein Requirements

• Adults: 1.5-2 g/kg/day 1
• Children: up to 3 g/kg/day 1

Formula Selection

• Use standard high-protein formula 1
• Consider glutamine supplementation for burn patients 1
  • Associated with reduced gram-negative bacteremia
  • Shorter hospital length of stay
  • Decreased hospital mortality

Monitoring and Adjustments

• For accurate assessment of energy needs, use predictive formulas specific to burn patients:

  • Adults: Toronto formula 1
  • Children: Schofield formula 1

• Provide micronutrient supplementation early 1:

  • Trace elements: copper, zinc, and selenium
  • Vitamins: B, C, D, and E

Implementation Challenges and Solutions

Common barriers to early EN implementation:

• Time lag between feeding tube placement and initiation of feeding (median 16h in one study) 6
• Concerns about feeding intolerance

Solutions:

• Develop standardized protocols for feeding tube placement and EN management 6
• For patients with feeding intolerance (high gastric residuals), consider:
  • IV administration of metoclopramide or erythromycin 1
  • Jejunal rather than gastric feeding 1

Outcomes and Monitoring

Regular monitoring should include:

• Nutritional parameters (albumin, transferrin) 2
• Inflammatory markers (C-reactive protein) 2
• Weight/BMI changes 2
• Signs of feeding intolerance

Special Considerations

For severely burned patients who cannot meet nutritional targets with EN alone:

• Consider supplemental parenteral nutrition 1
• Avoid excessive carbohydrate provision as it can propagate hyperglycemia 1

Early implementation of nutritional protocols has shown high compliance (80% within 24 hours, 95% within 48 hours) when formalized as standard operating procedure 3.