How should diabetes management be adjusted in a burn patient with 65% total body surface area burned and worsening hyperglycemia?

Management of Worsening Hyperglycemia in Burn Patients with 65% TBSA

Yes, severe worsening of diabetes is extremely common in burn patients with 65% TBSA burns, and insulin therapy should be initiated immediately with a target glucose range of 130-150 mg/dL to reduce mortality and morbidity. 1, 2

Understanding the Hypermetabolic Response

Burn patients with extensive injuries experience profound metabolic derangements that directly worsen glycemic control:

• Nearly all burn patients develop insulin resistance, with glucose oxidation increasing from 4-5 g/kg/day to 7 g/kg/day after thermal injury 1
• The hypermetabolic response can reach 180% of basal metabolic rate in the first week, remaining elevated at 130-150% at full healing and persisting up to 2 years post-injury 1
• This hypermetabolic state creates a perfect storm of hyperglycemia, inflammation, and immune suppression 1

Insulin Therapy: The Cornerstone of Management

Administer insulin therapy targeting blood glucose of 130-150 mg/dL, as this range provides mortality and morbidity benefits without significant hypoglycemia risk 2:

• Insulin administration improves lean body mass, bone mineral density, donor site healing, and decreases overall length of stay in severe burn injuries 1
• Careful monitoring is mandatory to avoid hypoglycemia, which remains the primary risk of insulin therapy 1, 3
• History of pre-existing diabetes increases hypoglycemia risk 15-fold (OR 15.4,95% CI: 2.5-95.1), requiring even more vigilant monitoring 3

Critical Pitfall to Avoid

Avoid tight glycemic control targeting <130 mg/dL, as the increased hypoglycemia risk outweighs benefits in burn patients 4, 2. The 130-150 mg/dL target represents the optimal balance between benefit and safety 2.

Nutritional Management to Control Hyperglycemia

Carbohydrate Management

Limit carbohydrate provision carefully, as excess carbohydrate after thermal injuries propagates hyperglycemia with subsequent exacerbation of inflammation, muscle breakdown, and excess fat production 1:

• These metabolic changes further suppress the immune system, placing patients at increased risk of life-threatening infection and sepsis 1
• Use serial indirect calorimetry (or Toronto formula if unavailable) to accurately determine energy needs and avoid overfeeding 1

Protein Requirements

Provide 1.5-2 g/kg/day of protein to address the hallmark protein catabolism of burn injuries, where patients oxidize amino acids at 50% higher than baseline 1:

• This protein supplementation increases protein synthesis and reduces negative nitrogen balance 1
• Protein rates exceeding 2 g/kg/day have not demonstrated additional benefits 1

Fat Composition

Consider low-fat diets to help avoid exaggerated immunosuppression 1:

• While omega-3 fatty acids are speculated to enhance immunity and reduce hyperglycemic episodes, a recent systematic review was unable to demonstrate benefit 1
• More research is needed, but low-fat approaches remain reasonable 1

Monitoring Strategy

Implement continuous glucose monitoring with careful attention to protocol adherence:

• Protocol violations account for 47% of hypoglycemic episodes, and glucose variability accounts for 30% 3
• Use a single, standardized insulin protocol to reduce errors—multiple different protocols contribute significantly to protocol violations and glucose variability 3
• Hypoglycemia occurs in approximately 1.1% of continuous insulin infusion hours, with two-thirds experiencing glucose <70 mg/dL 3

Early Nutritional Support

Initiate enteral nutrition within 24 hours of burn injury 1:

• Early EN decreases muscle protein catabolism, improves wound healing, decreases ICU and hospital length of stay, diminishes rates of sepsis, and decreases infectious load 1
• This early feeding helps modulate the hypermetabolic response and supports better glycemic control 1

Why This Matters for Outcomes

The rationale for aggressive glycemic management in this population is clear:

• Hyperglycemia suppresses immune function, increasing risk of life-threatening infection and sepsis 1
• Burn-induced hyperglycemia is directly associated with adverse clinical outcomes including increased mortality 4, 5
• Proper insulin therapy and nutritional management address both the hyperglycemia and the underlying hypermetabolic state 1, 2