Managing Fear and Pain in Major Burn Patients

Metabolic Response to Stress

• The metabolic response to critical illness, traumatic injury, sepsis, burns, or major surgery is complex and involves most metabolic pathways.
• Accelerated catabolism of lean body or skeletal mass occurs, resulting in net negative nitrogen balance and muscle wasting.

Ebb and Flow Phases

• The ebb phase occurs immediately after injury, characterized by:
  • Hypovolemia
  • Shock
  • Tissue hypoxia
  • Decreased cardiac output, oxygen consumption, and body temperature
• The flow phase follows fluid resuscitation and restoration of oxygen transport, characterized by:
  • Increased cardiac output, oxygen consumption, and body temperature
  • Increased energy expenditure and total body protein catabolism

Energy Expenditure and Nutrition

• Actual body weight is a better predictor of energy expenditure than ideal body weight in obese individuals.
• The Penn State University equation (2003b) or PSU equation (2010) should be used to estimate energy expenditure in obese and non-obese patients.
• Hypocaloric, high-protein nutrition support therapy or "permissive underfeeding" may be beneficial in critically ill obese patients.
• Protein requirements are difficult to determine in critically ill patients.
• Minimizing fear and pain can reduce catecholamine stimulation and energy expenditure.

Burns and Metabolic Response

• Burn patients have greatly accelerated metabolism and require increased energy, carbohydrates, proteins, fats, vitamins, minerals, and antioxidants.
• A healthy liver is essential for burn patients.
• Hepatic acute phase proteins are strong predictors of postburn survival.
• Goals of nutrition support therapy after major burn injury include:
  • Provision of adequate calories to meet energy needs
  • Prevention or correction of specific nutrient deficiencies
  • Fluid and electrolyte management for adequate urine output and normal homeostasis

Systemic Inflammatory Response Syndrome (SIRS) and Multiple Organ Dysfunction Syndrome (MODS)

• SIRS describes the widespread inflammation that can occur in infection, pancreatitis, ischemia, burns, multiple trauma, hemorrhagic shock, or immunologically mediated organ injury.
• MODS can develop as a complication of SIRS, characterized by:
  • Lung failure followed by failure of the liver, intestines, and kidney
  • Hematologic and myocardial failures may occur later
  • Central nervous system changes can occur at any time
• MODS can be primary or secondary, depending on the location of the initial injury.

Nutrition Support Therapy

• Enteral nutrition (EN) is preferred over parenteral nutrition (PN) whenever possible.
• Small bowel feedings are indicated when gastric residuals exceed 250 mL.
• Enteral tolerance should be monitored by assessing the level of pain, presence of abdominal distention, passage of flatus and stool, and physical examination.
• PN is indicated for patients in whom EN is unsuccessful or contraindicated.
• Immune-modulating enteral formulations may have beneficial effects and favorable outcomes for critically ill patients.