15 Nutrition Therapy in the Burn Care Setting: What Is Best Achievable Practice?
Authors: Heyland Daren , Ortiz Luis A , Garner Warren L , Mandell Samuel P , Colpaert Kirsten , Stoppe Christian , Day Andrew G 
Published: March 2020

Abstract

Introduction
The fourth most common injury worldwide are burn injuries. The uncontrolled inflammation, hyper-catabolism, and nutrient deficiencies associated with burn injuries can translate into worse clinical outcomes. Accordingly, CPGs recommends increasing energy requirements from 25–35 kcal/kg/day and provide 1.5–2 grams of protein/kg/day. Thus, the aim of this research is to evaluate the adherence level to CPGs recommendations in adult burn patients and describe the nutritional variability intake across Burn Units (BU) in North America (NA), Latin America (LATAM), and Europe (EU).

Methods
In a multi-national, multi-centre (n=43), double-blinded, controlled RCT of adult burn patients randomly allocated to receive either L-glutamine (0.5g/kg/day) or placebo via enteral nutrition (EN), we explored the nutritional adequacy. Patients with a deep 2nd-3rd degree burns were enrolled. Patients with renal failure, electrical injuries, BMI &lt; 18 or &gt; 50, liver cirrhosis, contraindication for EN, pregnancy, or moribund were excluded. BUs with &gt;5 burn patients with completed data were included in this analysis. Patient demographics, nutritional intake and clinical outcomes were collected. Nutritional adequacy was calculated from all sources (glucose and oral intake no collected). Descriptive analyses for quantitative data were performed. The data is presented as mean and standard deviation (±) or median with interquartile range [25th to 75th percentile]

Results
Six hundred and eight burn patients from 32 BUs were included. Overall, 75% (n=455) of the patients were male and Caucasians (78% [n=477]) with a median age of 51 [34–64] years, moderately ill (12 [8–19] APACHE II score), and the most common type of burn was fire (87% [n=530]) with a %TBSA of 27 [20–40], Table 1. Overall, 242 (40%) patients received artificial nutrition. The proportion of patients receiving EN alone at each BU averaged 84% [worst: 7% to best site:88%]. Overall, time from admission to start of EN was an average of 0.7 [0.4 – 0.9] days across all BUs [best:0.2 to worst site: 1.7 day]. PN+EN was used on 13% (n=31) of the patients [site range, 5–89%]. Average adequacy of calories at all sites was 71 % (site average range, 22–82 %) and 72 % (29%– 97%) for protein with greater adequacy observed in LATAM BUs and worst adequacy observed in NA BUs, Figure 1. At the site level, a total of 7 (21%) and 9 (28%) BU successfully achieved &gt;80% of calories and protein via artificial nutrition, respectively, Figure 2. The average use of motility agents in patients receiving &gt;80% at site level was 72 [60–85 %].

Conclusions
The actual energy and protein intake remains suboptimal in burn patients worldwide but tremendous variability exists across BU worldwide. Efforts to standardize and enhance EN delivery are warranted.

Applicability of Research to Practice
Compliance with clinical guidelines recommendations might improve clinical outcomes in burn victims.