Nutrition Therapy 1: Burns - University of Santo Tomas

20/09/2024 1 NUTRITION THERAPY 1...

20/09/2024 1 NUTRITION THERAPY 1 Document History (ND 7318) Developed by: UNIT 3 ASST. PROF. DIANE MENDOZA-SARMIENTO, RND, MSc. AY 2020-2021 Updated by: MS. JOANNA L. LUSTERIO, RND, MSc. AY 2023-2024 BURNS AY 2024-2025 University of Santo Tomas| 1st Sem AY 2024 -2025 University of Santo Tomas | 2024 2 3 OBJECTIVES BURNS Injured tissue caused by heat, chemicals, 1 University of Santo Tomas | 2024 Discuss classification of burns electricity or radiation, characterized by: Decreased of blood volume 2 Discuss the metabolic changes that occurs Plasma loss Edema 3 Discuss the nutritional requirements Damage to blood vessel wall Increased metabolic rate Image from Google Weight loss Nitrogen and nutrient loss hyperglycemia University of Santo Tomas | 2024 1  20/09/2024 4 5 PATHOPHYSIOLOGY PATHOPHYSIOLOGY initial burn shock is a result of the extensive inflammatory process Burns results in severe trauma : involves rapid fluid shifts and accumulation : fluid loss from the wound. Exaggerated protein catabolism: Increased nitrogen excretion(HYPERMETABOLISM) physiological response: hypermetabolism, catabolism, and altered immune and hormonal response. Susceptible to infection Respiratory complications are multifactorial: inhalation of smoke and other toxic substances or occur as complications secondary to fluid resuscitation, May develop ileus – loss of intestinal peristalsis pain, inflammation, and infection. Water loss University of Santo Tomas | 2024 University of Santo Tomas | 2024 6 7 CLINICAL MANIFESTATIONS CHARACTERISTICS Insulin Resistance Signs and symptoms experienced will be determined by the extent of the burn injury – depth & body surface area affected Hormonal changes; increased secretion of ADH and aldosterone, cathecolamines Age, nutritional status, and other comorbidities will have an impact on the physiological response to the injury, treatment, and recovery. Peristalsis is inhibited Electrolyte losses University of Santo Tomas | 2024 University of Santo Tomas | 2024 2  20/09/2024 CLASSIFICATION 8 RULE OF 9s 9 SUPERFICIAL – top layer of epidermis; skin would -rapid estimation of body characteristically redden (e.g. sunburn) surface area (BSA) that has been burned. PARTIAL THICKNESS DEEP BURN – destruction of epidermis and dermis FULL THICKNESS BURN – all skin layers are destroyed, involving underlying muscle or organ or bone University of Santo Tomas | 2024 University of Santo Tomas | 2024 Nutrition and Pathophysiology Images: Occupational Therapy and Physiotherapy for Patients with Burns: Principles and Management Guidelines. Journal of Burn Care and Rehabilitation.2003 10 11 TREATMENT NUTRITIONAL CONSIDERATIONS Management of the burn wound involves application of topical ▪ at significant nutritional risk agents such as silver sulfadiazine cream and silver nitrate to prevent infections. ▪ estimated that as much as 20% of body protein can be lost within the first two weeks of burn injury. Other treatment involves the complex procedures used to clean, debride, and dress the wounds. ▪ Difficulty to maintain nutritional status Full thickness burns require skin grafting or the use of skin substitutes for ▪ requires optimal nutrition therapy to support wound healing during the treatment and healing process. acceptable closure of the wounds. University of Santo Tomas | 2024 University of Santo Tomas | 2024 3  20/09/2024 12 13 Nutritional Care Goals Nutritional Care Goals 1. MINIMIZE METABOLIC RESPONSE 2. MEET NUTRITIONAL NEEDS Adequate kcal to prevent weight loss greater than 10% of usual body Control environmental temperature (warm environment) weight Maintain fluid & electrolyte balance Controlling pain and anxiety Adequate protein for + nitrogen balance & maintenance or repletion of circulating proteins Covering wounds early Vitamin and mineral supplementation, as indicated Wound healing only occurs in an anabolic state University of Santo Tomas | 2024 University of Santo Tomas | 2024 14 15 Dietary Management Diet Rationale Nutritional Requirements: Calories IVF To replace fluid losses Ireton-Jones Equation: Tube feeding when necessary to meet energy requirements (Obese) EE: 606 S + 9 W - 12A + 400 V +1444 (ventilator patients) EE: 1925 - 10A + 5W+ 281 S + 292 T + 851B Fluid & Na controlled To control water retention High Kcal To provide energy reserves A: age in years S: sex (1= male, 0= female) High PRO To regenerate tissues T: trauma (absent:0, present: 1) B: burn (absent:0, present: 1) High Vit. Minerals For energy metabolism W: weight in kg (actual) V: ventilator (absent:0, present: 1) University of Santo Tomas | 2024 University of Santo Tomas | 2024 4  20/09/2024 16 17 Nutritional Requirements: Calories Nutritional Requirements: Calories Curreri Formula: The Mifflin-St Jeor equations are: Adult (16-59 y.o) Male: BMR = 10×weight + 6.25×height - 5×age + 5 [ (25 Kcal x pre burn body weight (kg)) + (40 Kcal x TBSA (% burn)] Female: BMR = 10×weight + 6.25×height - 5×age – 161 Adult (>60 y.o) wt=kg; ht= cm; age=years [ (20 Kcal x pre burn body weight (kg)) + (65 Kcal x TBSA (% burn)] INJURY FACTORS: 1.3 to 1.5 to set initial kcal goals for patients. *this initial estimate falls between 25-35 kcal/kgbw If TBSA= >50%, a constant of 50% is used to avoid overestimation ISSUE: - overestimation of caloric requirements - overfeeding University of Santo Tomas | 2024 University of Santo Tomas | 2024 18 19 TER Computation TER Computation Harris Benedict Formula TORONTO EQUATION Males -4343 + (10.5 x %TBSA) + (0.23 x CI) + (0.84 x EBEE) + (114 x Temp (degree C)) - (4.5 x PBD) RMR= 66.47 + (13.75 x Weight (kg) ) + (5 x Height(cm)) –(6.76 x Age (yrs)) %TBSA: percent body surface are burned CI: Calorie intake for the past 24 hours Females EBEE: estimated basal energy expenditure (may use HBE) RMR= 655.1 + (9.56 x Weight (kg)) + (1.85 x height (cm)) – (4.68 x Age (yrs)) Temp: average temp for the last 24 hours( in Celsius) PBD: number of days after the injury *If overweight/obese: use adjusted body weight (more accurate results) University of Santo Tomas | 2024 University of Santo Tomas | 2024 5  20/09/2024 20 21 TER Computation Nutritional Requirements: Protein Curreri Formula: Adults: (1g CHON x preburnbw(kg) )+ (3 gCHON x TBSA) Children: (3g CHON x preburnbw(kg) )+ (1 gCHON x TBSA) Other Recommendations: 1.5-2.0 grams/kgbw/day 20-25% of TER - increased due to losses in the urine, wounds - gluconeogenesis and wound healing - Glutamine: conditionally essential - substrate for lymphocytes and enterocytes University of Santo Tomas | 2024 University of Santo Tomas | 2024 Nitrogen Balance 22 NITROGEN BALANCE 23 PROTEIN INTAKE (g) (URINARY UREA N MEASURE OF NET STATUS OF PROTEIN METABOLISM (g) + 2+2) - Does not measure protein status or nutritional status 6.25 - Useful to monitor changes in nutrition therapy BASED ON THE ASSUMPTION: Total body nitrogen is incorporated into protein Example: 55 kg bw Protein contains 16% Nitrogen 90 grams protein in a TF 90 grams Wound Nitrogen Losses 20 grams UUN excretion ________ - (20g + 2+ 2 + 1.1g) < 10% open wound 6.25 31% open wound = 0.12 grams/kg/day = -10.7 g NEGATIVE BALANCE University of Santo Tomas | 2024 University of Santo Tomas | 2024 6  20/09/2024 24 25 Nutrition Requirements: Nutrition Monitoring: CARBOHYDRATES : protein sparing : excess: hyperglycemia ▪ CALORIE COUNTING : 55-60% ▪ PROTEIN INTAKE LIPIDS : concentrated source of calories ▪ FLUID BALANCE : Omega 3 may help immunologic response ▪ EATING ABILITY Others: : Vit C, Copper, Selenium, Zinc - for wound healing University of Santo Tomas | 2024 University of Santo Tomas | 2024 University of Santo Tomas | 2024 THANK YOU GOD BLESS! 7