Burns — Metabolic & Nutritional Management

Also known as Burn hypermetabolism · Burn nutrition · Burn catabolism · Oxandrolone burn · Propranolol burn · Trace elements burn

The metabolic and nutritional management of the burns — the hypermetabolic response (the metabolic rate 150 to 200 per cent above normal; the massive catabolism, the hyperglycaemia). The early enteral nutrition (within 24 to 48 h). The high protein (1.5 to 2 g/kg/day). The trace elements (the zinc, the copper, the selenium). The anabolic (the oxandrolone, the propranolol, the insulin).

medium19 referencesUpdated 26 July 202614 min readVerification in progress

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8 MCQs

The one-line answer

The major burn is the most powerful sustained metabolic insult in critical care — a prospective multicentre study of severe burns measured energy expenditure as high as 2.7 times the basal metabolic rate in the first week after injury, sustained for weeks until the wound closes.^[10]^[13] The management is early enteral feeding, high protein at 1.5 to 2 g/kg/day in adults (3 g/kg/day in children),^[8] calories by indirect calorimetry — falling back to the Toronto formula when it is unavailable, because the Curreri formula over-estimates requirements^[8]^[10] — glucose at 8 mmol/L or less (never tight control, because hypoglycaemia is the dangerous end),^[8]^[5] and the pharmacological modulators propranolol (the catecholamine brake, titrated to a 15 to 20 per cent heart-rate reduction)^[9] and oxandrolone (the anabolic).^[3] Replete trace elements and vitamins early — intravenous zinc, copper, and selenium.^[8]^[6]

Meet the patient

A 42-year-old man is on day 7 of admission for a 50 per cent TBSA flame burn. He is tachycardic at 128 in sinus rhythm, his temperature is 38.6 degrees C, his blood glucose is 14 mmol/L despite an insulin infusion at 8 units per hour, and he has lost 6 kg since admission. Indirect calorimetry shows a resting energy expenditure of 1.8 times the Harris-Benedict prediction. The wound is only 40 per cent excised and grafted.^[10]^[5]

Every one of those numbers is the hypermetabolic response doing exactly what it does — and every one of them is the target of a specific therapy. The tachycardia and the fever are the catecholamine surge; the glucose is insulin resistance; the weight loss is unrestrained muscle catabolism; the energy expenditure is the open wound demanding substrate. The job of the intensivist is to flatten each limb of that cascade.^[3]

References19Show

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[3]Herndon DN, Tompkins RG Support of the metabolic response to burn injury Lancet, 2004.PMID 15183630
[4]Jeschke MG, et al. Intensive insulin therapy in severely burned pediatric patients: a prospective randomized trial Am J Respir Crit Care Med, 2010.PMID 20395554
[5]Jeschke MG, et al. Glucose Control in Severely Burned Patients Using Metformin: An Interim Safety and Efficacy Analysis of a Phase II Randomized Controlled Trial Ann Surg, 2016.PMID 27355267
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[13]Mendonça Machado N, Gragnani A, Masako Ferreira L Burns, metabolism and nutritional requirements Nutr Hosp, 2011.PMID 22470012
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[18]Manzanares W Thiamine supplementation in the critically ill Curr Opin Clin Nutr Metab Care, 2011.PMID 21912244
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