Clinician’s Guide to nutritional therapy in major burn patients

Burn injury is the ultimate trauma condition. Major burn patients are by far the more challenging population in the hospital, characterized by a severe inflammatory response, high oxidative stress, and a prolonged hypermetabolic and catabolic response. Nutrition is vital to treatment and recovery of burn patients, in this settings in not a matter only of feeding but above all an important part of his treatment. Massive fluid shifts immediately following injury, hypermetabolism as early as 24 hours postburn (lasting for up to 2 years), increased risk for loss of lean body mass, and potentially damaging free radial production all indicate the need for targeted and often aggressive medical nutrition therapy to improve clinical outcomes following major burns. Choosing the nutrition plan must take in consideration that: feeding can lead to muscle wasting and delays in wound healing but overfeeding can have equally serious complications, such as hyperglycaemia, fatty liver, and prolonged ventilator dependency. An understanding the physiologic response to burn stress is necessary and vital to apply the best nutritional treatment. By definition major burn injuries can be defined as injuries with greater than 20% burned total body surface area (TBSA), and severe burns can be defined as greater than 40% TBSA. Is this patients there is an increase in energy expenditure and metabolic rate, which can still be at 120% 6 months postburn. The metabolism homeostasis is completely lost, the organism suffers, lipolysis, liver dysfunction, severe muscle catabolism with net protein loss, insulin resistance, increase in cytokine levels, and decrease in sex hormones and endogenous growth hormone release. The increased metabolism and hyperdynamic circulation can lead to fatality if untreated. Three options exist for route of nutrition therapy: oral, enteral, and parenteral. In major burns, in most of the times oral is not an option, between the other two, the enteral is the first choice, maintains gut integrity, supports a healthy immune system. The best time to start is early as 4 to 6 hours postburn. As all of us know every therapeutic approach in burn patient should be individualized, nutrition involves not only adequate calorie, protein, and fluid intake but also vitamin and mineral supplementation.