NUTRITIONAL CARE OF THE PATIENT WITH BURNS
Nutritional Tips for Patient with Burns
The burned patient, especially one with extensive burns, presents a tremendous nutritional challenge. His nutrition care is often the determining factor in his survival and healing. His feeding program is adjusted to individual needs and follows three distinct periods after the injury.
Immediate shock period (days 1 to 3)
A massive flooding edema occurs at the burn site during the first hours after the second day. Loss of enveloping skin surface and exposure of tissue fluids lead to immediate loss of water and electrolytes, mainly sodium, and large protein depletion. In an effort to balance this loss the water shifts from the other tissue spaces in the body but only adds to the continuous loss at the burn site. As a result the water circulating in the blood is withdrawn, thus decreasing the blood volume and pressure. A concentration of blood and diminished urine output occur as a result. Cell dehydration follows as cell water is drawn out to balance the tissue fluid losses. Cell potassium is also withdrawn and circulating serum potassium levels rise.
Immediate intravenous fluid therapy seeks to replace three constituents:
(1) Colloid (protein) through blood or plasma transfusion or by plasma expanders such as Dextran
(2) The electrolytes sodium and chlorine by use of a saline lactated Ringer’s solution, and
(3) Water (dextrose solution) to cover additional involuntary losses. The rate of flow should be carefully monitored. Half the calculated fluid and electrolytes has to be given during the first 8 hours, one fourth during the second 8 hours, and one fourth during the third 8 hours. During the second 24-hour period the patient will require about half the amount of fluid given during the first 24 hours.
Recovery period (days 3 to 5)
As the initial replacement fluid and electrolytes are gradually reabsorbed into the general circulation, balance is established, and the pattern of massive tissue loss is reversed. At this point a sudden dieresis occurs, indicating successful therapy. Intravenous therapy should then be discontinued and oral solutions of water and electrolytes used. One such oral solution is holdrane’s solution. It is made up of 3 to 4 gm. (½ teaspoon) salt, 1½ to 2gm. (1½ teaspoon) sodium bicarbonate (baking soda), and 1,000ml. (1 quart) water flavored with lemon juice and chilled. A careful check of fluid intake and output is essential, and constant checks for signs of dehydration and over hydration should be made.
Secondary feeding period (days 6 to 15)
Despite the patient’s depression and lack of appetite at this point, his life may well depend on rigorous nutritional therapy during this secondary feeding period. He may need to be fed by a tube, but oral feeding should be encouraged and supported as much as possible. He needs a high protein intake, 150 to as high as 400 gm., to counteract tissue destruction by the burn and tissue breakdown afterward with continued nitrogen losses and to fulfill the increased metabolic demands of infection or fever. From 3,500 to 5,000 calories with a high percentage of carbohydrate is necessary to meet these demands. Extra vitamin C therapy, 1 to 2gm., is needed for tissue regeneration. Increased thiamine, riboflavin, and niacin are necessary to supply oxidative enzyme systems to metabolize extra carbohydrate and protein loads. Optimum tissue health is necessary for the subsequent grafting to be successful. Since these nutritional needs are so vital, a careful record of protein and calorie intake and the amount of food consumed is a necessary tool for planning care. After initial liquid feedings using concentrated protein hydrolysates a soft to regular diet will probably be taken by the second week or so. Much continued support and effort is needed to encourage the patient to eat, supplying items he likes.