What are the essential micronutrients for burn patients?

Essential Micronutrients for Burn Patients

The essential micronutrients for burn patients include vitamins A, B-1, B-6, B-12, C, D, and E as well as minerals such as copper, selenium, zinc, iron, calcium, and magnesium, which are critical for wound healing, immune function, and reducing complications such as infections and prolonged hospitalization. 1

Key Micronutrients and Their Roles

Vitamins

• Vitamin A: Promotes granulation tissue formation, increases collagen synthesis, enhances re-epithelialization and fibroplasia 2
• Vitamin B-1 (Thiamine): Critical for energy metabolism; deficiency risk increases with continuous renal replacement therapy (CRRT) 1
• Vitamin B-6: Important for protein metabolism and immune function 1
• Vitamin C:
  • Functions as an antioxidant against oxygen-free radical generation
  • Decreases total fluid requirements and wound edema when used in resuscitation fluids
  • May reduce severity of respiratory dysfunction
  • Caution: Increases risk of postburn acute kidney injury 1
• Vitamin D: Supports immune function and wound healing 1
• Vitamin E: Present in lipid emulsions; important antioxidant 1

Minerals

• Copper: Particularly important in burn patients; deficiency is unique to major burns 3
• Selenium: Critical for antioxidant defense mechanisms; at high risk of depletion 1, 3
• Zinc: Essential for wound healing and immune function 1
• Iron: Supports oxygen transport and wound healing 1
• Calcium and Magnesium: Support wound healing and reduce infection risk 1
• Carnitine: Particularly important to monitor in patients on CRRT 1

Monitoring and Supplementation Guidelines

Monitoring Recommendations

• For major burn patients, especially those on CRRT for >5 days, regular monitoring of key micronutrients is encouraged, particularly:

  • Copper
  • Selenium
  • Vitamins B-1, B-6, and C
  • Carnitine 1

• For prolonged PN in critically ill burn patients, monthly determination of plasma concentrations enables detection of deficiencies, with particular attention to selenium and zinc 1

Supplementation Approach

1. Early supplementation: Begin micronutrient supplementation early in burn management 1

2. Dosing considerations:

   • Standard "1 daily dose" approach is insufficient for burn patients 1
   • Doses should be adapted in proportion to other substrates and with regard to underlying disease 1
   • For patients on CRRT: 2-3 vials of standard multivitamin preparations daily, particularly for water-soluble vitamins 1

3. Route of administration:

   • IV route appears to be the only way to deliver doses required for clinical effect in major burns 3
   • For less severe burns, enteral supplementation may be sufficient

Clinical Evidence and Outcomes

Supplementation of calcium, magnesium, and vitamins A, B-1, B-6, B-12, C, D, and E has demonstrated significant clinical benefits:

• Reduced wound infection risk (30% vs 77.4%, P<0.001)
• Decreased sepsis incidence (13.3% vs 41.9%, P=0.021)
• Shortened hospitalization (51.8 vs 76.8 days, P=0.025) 1

Important Considerations and Pitfalls

1. Dosing pitfalls:

   • Avoid using standard "1 daily dose" approach regardless of body weight or metabolic rate 1
   • Consider weight-based dosing for significant weight differences 1

2. Route of administration:

   • IV administration may be necessary for severe burns to achieve therapeutic levels 3
   • Absorption may be compromised in burn patients

3. Monitoring challenges:

   • Regular monitoring is essential but often overlooked
   • Pay special attention to patients on CRRT who have increased losses of water-soluble micronutrients 1

4. Vitamin C caution:

   • While beneficial for fluid requirements and wound edema, vitamin C-enriched resuscitation fluids increase risk of postburn acute kidney injury 1

5. Evidence limitations:

   • No evidence-based practice guidelines currently exist specifically for vitamin and mineral supplementation after thermal injuries 1
   • Limited high-quality trials focused on severe burn injury 4

Despite these limitations, given the low risk associated with low-dose mineral supplementation, micronutrient support should be considered in patients with severe burns, with particular attention to monitoring those on CRRT for extended periods 1.