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Recommendations for specialized nutritional-metabolic treatment of the critical patient
DOI: 10.1016/j.medine.2020.01.004
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Available online 13 March 2020
Recommendations for specialized nutritional-metabolic management of the critical patient: Special situations, polytraumatisms and critical burn patients. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)
Recomendaciones para el tratamiento nutrometabólico especializado del paciente crítico: paciente politraumatizado y paciente quemado crítico. Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC)
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A. Blesa-Malpicaa,
Corresponding author
ablesamal@gmail.com

Corresponding author.
, A. Martín-Luengob, A. Robles-Gonzálezc
a Servicio de Medicina Intensiva, Hospital Universitario Clínico San Carlos, Madrid, Spain
b Servicio de Medicina Intensiva, Hospital Universitario de Burgos, Burgos, Spain
c Servicio de Medicina Intensiva, Hospital Universitario Vall d’Hebron, Barcelona, Spain
Received 27 September 2019. Accepted 03 January 2020
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Table 1. Toronto formula used in adult major burn patients.
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Introduction

In polytraumatized patients, the extent of the injuries determines malnutrition risk, with the need for nutritional support measures. In major (critical) burn victims, nutritional management is required because of the intense catabolic response and tissue repair needs. Patients with burns affecting 40% of their body surface may present a 40%–80% increase in basal energy expenditure during the acute phase of the disorder.

The consumption of muscle mass is a result of protein catabolism exceeding protein synthesis. In effect, muscle mass acts as a substrate for the production of acute phase proteins, neoglycogenesis and healing of the wounds.

Stress hyperglycemia in the burn victim is a prolonged situation,1,2 and failure to control it adequately results in poor wound healing, graft loss and the exacerbation of muscle catabolism.

The use of indirect calorimetry is particularly relevant in patients of this kind. In non-septic patients and individuals in which the energy supply is not excessive (overfeeding), the provision of proteins runs parallel to survival.3 The recommendation in such cases is to administer a low fat and high protein diet.2

Do the caloric and protein requirements of these patients differ from those of the rest of critical patients?

The stress response generated by injuries of this kind requires a protein supply that is greater than in other critical patients.4 The adult burn and/or polytraumatized patient is estimated to need 1.5−2g/kg/day of protein.5–7

The caloric requirements do not seem to increase very much. Carbohydrate supply should not exceed 4−5g/kg/day (though amounts of up to 7g/kg/day have been described).1 The lipid supply in turn should represent less than 10% of the non-protein caloric needs, and in no case should it exceed 30% of the total calories. This measure appears to improve protein utilization.1,4

The gold standard is indirect calorimetry with a supply limited to 100% of the calculated value. In the absence of indirect calorimetry, the Harris-Benedict equation with a factor of 1.3–1.5 affords an approximate idea of the caloric requirements. In burn cases, the Toronto equation8 (Table 1) seems to be the best option, though other formulas have also been used, such as the Carlson equation9 or 25kcal+(30−40kcal×% burned body surface area).10

Table 1.

Toronto formula used in adult major burn patients.

−4.343 + (10.5*burned surface%) + (0.23*caloric intake) + (0.84*HB) + (114*T) − (4.5*days elapsed) 

HB: Harris-Benedict equation; T: temperature.

In the management of these patients, the three key elements of metabolic support are control of the hypermetabolic situation, of muscle consumption and of stress hyperglycemia.2 An adequate protein supply will not always be possible with the usual formulas, and in such situations protein supplements will prove necessary.

What is the most advisable administration route in these patients?

Feeding via the enteral route is advised, even using the postpyloric route, in the very early stages (first 6h) of injury,1,11 and preferably as close as possible to the jejunum. Use of the parenteral route should be considered if necessary to ensure the required nutrient supply. When correctly used, this technique is safe.12 The high metabolic demands of burn victims may require combined utilization of the enteral and parenteral routes.13

Do diets enriched with glutamine and other pharmaconutrients play a role?

Glutamine (Gln) supplementing in the critically ill is subject to controversy resulting from the Redox trial,14 which proves inappropriate, the Signet study,15 which is insufficient, and the Metaplus trial,16 which only reports adverse effects, with an objective not established in the design and involving a subgroup of medical patients. Burn and/or polytraumatized patients constituted a minority presence in all of them.

Consideration of the use of such enrichment measures is recommended in trauma and burn victims. It is advisable to determine their plasma levels, use an adequate dose (0.2–0.5g/kg/day),17 with early introduction, and continue administration for a period of over 5 days.

Glutamine favors a decrease in infections, a shortening of hospital stay,17 and lesser in-hospital mortality.18,19 Its intervention in the production of heat shock proteins, the regulation of hyperglycemia, action upon the immune cells and participation as an antioxidant are the suggested mechanisms underlying its beneficial effects in the critical patient.19,20 However, all this is subject to correct compliance with the known conditioning criteria, such as the absence of multiorgan failure (particularly in the presence of acute renal failure), dosing, treatment duration and use of the parenteral route. According to the available data, patients with diminished plasma Gln levels that are able to increase these levels once supplementing has started are the individuals that benefit most.21

Arginine is involved in hormone release, the reduction of insulin resistance and in the healing process, with action upon the blood vessels via the nitric oxide pathway, and has other known effects in surgical patients. As a result, it is very likely to offer benefits in critical burn and trauma patients - though specific studies in these fields are lacking.22–24 With regard to the use of omega-3 fatty acids, there is no strong evidence warranting their administration in patients of this kind,25,26 though their immune modulating effects could justify their use.

Supplementing with selenium and other micronutrients (zinc and copper) appears to be of benefit, though there is no clear consensus regarding the indicated amounts. In any case, the advised doses exceed the standard doses.27–29 The studies found in the literature mostly involve small patient samples and report that such supplements shorten wound healing time and hospital stay, and reduce the number of nosocomial infections and patient mortality.30,31

Of the drugs used in major burn victims, oxandrolone32 is advised over the long term at a dose of 0.1mg/12h via the oral route.33 Beta-blockers have shown benefits in children34–36 and could also be useful in adults.

Recommendations

  • -

    It is advisable to determine the requirements using indirect calorimetry during the early phases (Level of evidence: low. Grade of recommendation: low).

  • -

    It is believed that patients with burns affecting more than 20% of their body surface should receive early nutrition via the oral route, and if this is not possible, via the gastric or postpyloric route (Level of evidence: moderate. Grade of recommendation: high). If the required caloric supply cannot be met, complementary nutrition (parenteral) is advised (Level of evidence: low. Grade of recommendation: low).

  • -

    A supply of 1.5−2g/kg/day of protein is recommended, with over 70% of the non-protein calories in the form of carbohydrates, and limiting lipids to complete the caloric total (Level of evidence: moderate. Grade of recommendation: low).

  • -

    It is advisable to use pharmaconutrients such as Gln (0.2–0.5g/kg/day) (Level of evidence: moderate. Grade of recommendation: high) and arginine (Level of evidence: low. Grade of recommendation: low).

  • -

    In trauma and burn victims it is advisable to supplement the diet with selenium, zinc and other micronutrients, and doses higher than those used in medical critical patients are probably indicated (Level of evidence: moderate. Grade of recommendation: low).

  • -

    In critical burn victims it is advisable to administer oxandrolone at a dose of 0.1mg/kg/12h via the oral route (Level of evidence: moderate. Grade of recommendation: moderate), as well as beta-blockers (Level of evidence: low. Grade of recommendation: low).

Note to supplement

This article forms part of the supplement “Recommendations for specialized nutritional-metabolic management of the critical patient. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)”, with the sponsorship of Abbott Nutrition.

Conflicts of interest

The authors declare that they have no conflicts of interest.

References
[1]
K.L. Hall, S. Shahrokhi, M.G. Jeschke.
Enteral nutrition support in burn care: a review of current recommendations as instituted in the Ross Tilley Burn Centre.
Nutrients., 4 (2012), pp. 1554-1565
[2]
C. Porter, R.G. Tompkins, C.C. Finnerty, L.S. Sidossis, O.E. Suman, D.N. Herndon.
The metabolic stress response to burn trauma: current understanding and therapies.
Lancet, 388 (2016), pp. 1417-1426
[3]
P.J. Weijs, W.G. Looijaard, A. Beishuizen, A.R. Girbes, H.M. Oudemans-van Straaten.
Early high protein intake is associated with low mortality and energy overfeeding with high mortality in non-septic mechanically ventilated critically ill patients.
[4]
A. Abdullahi, D. Patsouris, S.R. Costford, M.G. Jeschke.
Hypermetabolic response to burn injury.
The stress response of critical illness: metabolic and hormonal aspects, pp. 227-245
[5]
G.E. O’Keefe, M. Shelton, J. Cuschieri, E.E. Moore, S.F. Lowry, B.G. Harbrecht, et al.
Inflammation and the host response to injury, a large-scale collaborative project: patient-oriented research core–standard operating procedures for clinical care VIII–nutritional support of the trauma patient.
J Trauma., 65 (2008), pp. 1520-1528
[6]
R.N. Dickerson, S.L. Pitts, G.O. Maish Iii, T.J. Schroeppel, L.J. Magnotti, M.A. Croce, et al.
A reappraisal of nitrogen requirements for patients with critical illness and trauma.
J Trauma Acute Care Surg., 73 (2012), pp. 549-557
[7]
M. Nicolo, D.K. Heyland, J. Chittams, T. Sammarco, C. Compher.
Clinical outcomes related to protein delivery in a critically ill population.
JPEN J Parenter Enteral Nutr., 40 (2015), pp. 45-51
[8]
J.P. Allard, C. Pichard, E. Hoshino, S. Stechison, L. Fareholm, J.P. Walters, et al.
Validation of a new formula for calculating the energy requirements of burn patients.
JPEN J Parenter Enteral Nutr., 14 (1990), pp. 115-118
[9]
D.E. Carlson, W.G. Cioffi Jr., A.D. Mason Jr., W.F. McManus, B.A. Pruitt Jr..
Resting energy expenditure in patients with thermal injuries.
Surg Gynecol Obstet., 174 (1992), pp. 270-276
[10]
T. Nunez-Villaveiran, M. Sanchez, P. Millan, J.R. Martinez-Mendez, C. Iglesias, C. Casado-Perez, et al.
[Energy expenditure prediction equations in burn patients; bibliographic review] Spanish.
Nutr Hosp., 29 (2014), pp. 1262-1270
[11]
F.N. Williams, L.K. Branski, M.G. Jeschke, D.N. Herndon.
What, how, and how much should patients with burns be fed?.
Surg Clin North Am., 91 (2011), pp. 609-629
[12]
S.E. Harvey, F. Parrott, D.A. Harrison, D.E. Bear, E. Segaran, R. Beale, et al.
Trial of the route of early nutritional support in critically ill adults.
N Engl J Med., 371 (2014), pp. 1673-1684
[13]
R. Khorram-Sefat, W. Behrendt, A. Heiden, R. Hettich.
Long-term measurements of energy expenditure in severe burn injury.
World J Surg., 23 (1999), pp. 115-122
[14]
D. Heyland, J. Muscedere, P.E. Wischmeyer, D. Cook, G. Jones, M. Albert, et al.
A randomized trial of glutamine and antioxidants in critically ill patients.
N Engl J Med, 368 (2013), pp. 1489-1497
[15]
P.J. Andrews, A. Avenell, D.W. Noble, M.K. Campbell, B.L. Croal, W.G. Simpson, et al.
Randomised trial of glutamine, selenium, or both, to supplement parenteral nutrition for critically ill patients.
BMJ, 342 (2011),
[16]
A.R.H. van Zanten, F. Sztark, U.X. Kaisers, S. Zielmann, T.W. Felbinger, A.R. Sablotzki, et al.
High-protein enteral nutrition enriched with immune-modulating nutrients vs standard high-protein enteral nutrition and nosocomial infections in the ICU.
JAMA, 312 (2014), pp. 514-524
[17]
M. Kim, P.E. Wischmeyer.
Glutamine.
World Rev Nutr Diet., 105 (2013), pp. 90-96
[18]
J.-J. Lin, X.-J. Chung, C.-Y. Yang, H.-L. Lau.
A meta-analysis of trials using the intention to treat principle for glutamine supplementation in critically ill patients with burn.
[19]
P.E. Wischmeyer, R. Dhaliwal, M. McCall, T.R. Ziegler, D.K. Heyland.
Parenteral glutamine supplementation in critical illness: a systematic review.
[20]
R.M. Al Balushi, J. Cohen, M. Banks, J.D. Paratz.
The clinical role of glutamine supplementation in patients with multiple trauma: a narrative review.
Anaesth Intensive Care., 41 (2013), pp. 24-34
[21]
J. Perez-Barcena, P. Marse, A. Zabalegui-Perez, E. Corral, R. Herran-Monge, M. Gero-Escapa, et al.
A randomized trial of intravenous glutamine supplementation in trauma ICU patients.
Intensive Care Med., 40 (2014), pp. 539-547
[22]
B.P. Costa, P. Martins, C. Veríssimo, M. Simões, M. Tomé, M. Grazina, et al.
Argininemia and plasma arginine bioavailability–predictive factors of mortality in the severe trauma patients?.
Nutr Metab (Lond), 13 (2016), pp. 1-9
[23]
J.W. Drover, R. Dhaliwal, L. Weitzel, P.E. Wischmeyer, J.B. Ochoa, D.K. Heyland.
Perioperative use of arginine-supplemented diets: a systematic review of the evidence.
J Am Coll Surg., 212 (2011), pp. 385
[24]
J.J. Patel, K.R. Miller, C. Rosenthal, M.D. Rosenthal.
When is it appropriate to use arginine in critical illness?.
Nutr Clin Pract., 31 (2016), pp. 438-444
[25]
T. Mayes, M.M. Gottschlich, R.J. Kagan.
An evaluation of the safety and efficacy of an anti-inflammatory, pulmonary enteral formula in the treatment of pediatric burn patients with respiratory failure.
J Burn Care Res., 29 (2008), pp. 82-88
[26]
J.W. Alexander, H. Saito, O. Trocki, C.K. Ogle.
The importance of lipid type in the diet after burn injury.
[27]
B.R. Collier, A. Giladi, L.A. Dossett, L. Dyer, S.B. Fleming, B.A. Cotton.
Impact of high-dose antioxidants on outcomes in acutely injured patients.
JPEN J Parenter Enteral Nutr., 32 (2008), pp. 384-388
[28]
A.M. Giladi, L.A. Dossett, S.B. Fleming, N.N. Abumrad, B.A. Cotton.
High-dose antioxidant administration is associated with a reduction in post-injury complications in critically ill trauma patients.
[29]
M.M. Berger, L. Soguel, A. Shenkin, J.-P. Revelly, C. Pinget, M. Baines, et al.
Influence of early antioxidant supplements on clinical evolution and organ function in critically ill cardiac surgery, major trauma, and subarachnoid hemorrhage patients.
Crit Care., 12 (2008), pp. R101
[30]
M. Adjepong, P. Agbenorku, P. Brown, I. Oduro.
The role of antioxidant micronutrients in the rate of recovery of burn patients: a systematic review.
Burns Trauma, 4 (2016), pp. 18
[31]
R. Kurmis, J. Greenwood, E. Aromataris.
Trace element supplementation following severe burn injury: a systematic review and meta-analysis.
J Burn Care Res, 37 (2016), pp. 143-159
[32]
H. Li, Y. Guo, Z. Yang, M. Roy, Q. Guo.
The efficacy and safety of oxandrolone treatment for patients with severe burns: a systematic review and meta-analysis.
[33]
D.W. Hart, S.E. Wolf, P.I. Ramzy, D.L. Chinkes, R.B. Beauford, A.A. Ferrando, et al.
Anabolic effects of oxandrolone after severe burn.
Ann Surg., 233 (2001), pp. 556-564
[34]
D.N. Herndon, D.W. Hart, S.E. Wolf, D.L. Chinkes, R.R. Wolfe.
Reversal of catabolism by beta-blockade after severe burns.
N Engl J Med., 345 (2001), pp. 1223-1229
[35]
G.G. Gauglitz, F.N. Williams, D.N. Herndon, M.G. Jeschke.
Burns: where are we standing with propranolol, oxandrolone, recombinant human growth hormone, and the new incretin analogs?.
Curr Opin Clin Nutr Metab Care, 14 (2011), pp. 176-181
[36]
A.A. Mohammadi, A. Bakhshaeekia, P. Alibeigi, M.J. Hasheminasab, H.R. Tolide-ei, A.R. Tavakkolian, et al.
Efficacy of propranolol in wound healing for hospitalized burn patients.
J Burn Care Res., 30 (2009), pp. 1013-1017

Please cite this article as: Blesa-Malpica A, Martín-Luengo A, Robles-González A. Recomendaciones para el tratamiento nutrometabólico especializado del paciente crítico: paciente politraumatizado y paciente quemado crítico. Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC). Med Intensiva. 2020. https://doi.org/10.1016/j.medin.2020.01.001

Copyright © 2020. Elsevier España, S.L.U. and SEMICYUC
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