- Email: [email protected]
Compliance with nutrition support guidelines in acutely burned patients
burns 38 (2012) 645–649
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Compliance with nutrition support guidelines in acutely burned patients Brennen Holt, Caran Graves, Iris Faraklas, Amalia Cochran * Burn Center at the University of Utah, United States
article info
abstract
Article history:
Background: Adequate and timely provision of nutritional support is a crucial component of
Accepted 9 December 2011
care of the critically ill burn patient. The goal of this study was to assess a single center’s consistency with Society of Critical Care Medicine/American Society for Parenteral and
Keywords:
Enteral Nutrition (SCCM/ASPEN) guidelines for nutritional support in critically ill patients.
Nutrition
Methods: Acutely burned patients >45 kg in weight admitted to a regional burn center during
Critical illness
a two-year period and who required 5 or more days of full enteral nutritional support were
Burns
eligible for inclusion in this retrospective review. Specific outcomes evaluated include time from admission to feeding tube placement and enteral feeding initiation and percent of nutritional goal received within the first week of hospital stay. Descriptive statistics were used for all analyses. IRB approval was obtained. Results: Thirty-seven patients were included in this retrospective review. Median age of patients was 44.9 years (IQR: 24.2–55.1), and median burn injury size was 30% (IQR: 19–47). Median time to feeding tube placement was 31.1 h post admission (IQR: 23.6–50.2 h), while median time to initiation of EN was 47.9 h post admission (IQR: 32.4–59.9 h). The median time required for patients to reach 60% of caloric goal was 3 days post-admission (IQR: 3–4.5). Conclusion: The median time for initiation of enteral nutrition was within the SCCM/ASPEN guidelines for initial nutrition in the critically ill patient. This project identified a 16 h time lag between placement of enteral access and initiation of enteral nutrition. Development of a protocol for feeding tube placement and enteral nutrition management may optimize early nutritional support in the acutely injured burn patient. # 2012 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Severe burns lead to a hypermetabolic response that is more dramatic than that identified in any other disease or injury [1]. Metabolic rates may exceed 200% of normal, depending on factors that include total body surface area (TBSA) injured, body mass, age, and time from injury to excision of eschar [2,3]. A variety of physiologic processes are thought to cause this hypermetabolic response and the consequences of this complex response can be life threatening. Loss of lean body mass,
decreased immune response, and delayed wound healing are all major manifestations associated with the hypermetabolic response that impact hospital length of stay, morbidity, and mortality. Appropriate and adequate nutrition does play a role in attenuation of this response [4]. Studies have also demonstrated hospital length of stay and morbidity rates increase when adequate nutritional support (NS) is not provided [5,6]. Nutrition support in the critically ill has been shown to help maintain intestinal barrier function [7], prevent bacterial translocation [8], and conserve bowel mucosal integrity [9], further showing that timely provision of NS is a vital
* Corresponding author at: University of Utah, Department of Surgery, 30 North 1900 East, SOM 3B313, Salt Lake City, UT 84132, United States. Tel.: +1 801 581 7508; fax: +1 801 587 9149. E-mail address: [email protected] (A. Cochran). 0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2011.12.002
646
burns 38 (2012) 645–649
Table 1 – SCCM/ASPEN guidelines evaluated [13]. EN is the preferred route of feeding over parenteral nutrition (PN) for the crtically ill patient who requires nutrition support therapy. Enteral feeding should be started early within the first 24–48 h following admission. The feedings should be advanced toward goal over the next 48–72 h. In the setting of hemodynamic compromise, EN should be withheld until the patient is fully resuscitated and/or stable. The target goal of EN (defined by energy requirements) should be determined and clearly identified at the time of initiation of nutrition support therapy. Energy requirements may be calculated by predictive equations or measured by indirect calorimetry. Efforts to provide >50% to 65% of goal calories should be made to achieve the clinical benefit of EN over the first week of hospitalization. Guidelines in bold are those that were measured for this study.
component of burn care [10]. While multiple studies indicate that ICU patients are often underfed and that care processes may contribute to this, the process of initiation of nutritional support in critically ill burn patients has not been examined [11,12]. Therefore, the primary purpose of this retrospective review is to compare a single center’s enteral nutrition (EN) practices to guidelines published by the Society of Critical Care Medicine (SCCM)/American Society for Parenteral and Enteral Nutrition (ASPEN) [13]. Specifically, we will assess our center’s compliance with identified best practices for feeding tube (FT) placement time, EN start time, and percent of nutritional goal received within the first week of hospital stay (Table 1).
2.
Methods
2.1.
Data collection
This IRB-approved retrospective review included acutely burned pediatric patients who weighed 45 kg or more and adults who were admitted to a regional American Burn Association verified burn center for treatment from January 1, 2007 through December 31, 2008. Patients admitted for non-thermal illness or patients who suffered multisystem trauma in conjunction with their burns were excluded. The institutional data warehouse was used to identify all acutely burned patients who received enteral nutritional support with no oral intake for at least five consecutive days within the first week following admission. Data collected from patient medical records included basic demographics (age and gender), anthropometrics, burn injury characteristics (total and full-thickness TBSA), presence of inhalation injury, time from admission until post-pyloric FT placement, time until EN was started, time until 60% of nutritional goal was achieved, and what percentage of time goal was achieved during Week 1 while receiving EN. Patient hospital length of stay and number of days ventilated were recorded, as were time until initial indirect calorimetry (IC) and any reasons documented for failure to reach feeding goals. Patients who were unable to achieve caloric goals via oral intake within 72 h of admission underwent FT placement and administration of EN. These patients were excluded
from analysis of the length of time from admission to FT placement and time to EN commencement. Calculated total daily caloric value was the sum of intravenous infusions and enteral feeding calories received in 24 h for each day that EN was provided. The published manufacturer’s caloric information for IV infusions and EN were used to calculate the daily caloric amount.
2.2.
Nutrition support
Acute burn patients deemed unlikely to achieve their caloric goals with oral intake alone as assessed by the attending surgeon in consultation with the unit dietician at the time of admission had a FT placed. Per unit standard, FTs were placed under fluoroscopic guidance into the small intestine. Once a FT was in position and the patient was determined by the attending surgeon to have no clinical manifestations of shock, EN was initiated. EN was held for 6 h prior to surgery per anesthesiology directive in non-intubated patients but was not routinely stopped for other procedures nor in intubated patients. ‘‘Catch up’’ feeds when feeds were held for OR or travel were not provided. EN was held until TF placement could be radiographically confirmed for a gastric residual of >200 ml or TF in the NG tube; these same criteria were used to define suspected feeding intolerance. Basal energy expenditure (BEE) was estimated using the Harris–Benedict formula [14], a widely accepted predictive equation. In burn patients, caloric needs have been estimated by multiplying BEE by a factor ranging from 1.2 to 2.0 [15]. In this unit, the Registered Dietitian (RD) calculated the initial caloric goal rate based upon 135% of the Harris–Benedict equation (HB135), and this was used until indirect calorimetry was available. IC, commonly referenced as the gold standard for determining caloric needs in the critically ill, estimates energy expenditure by measuring basal energy needs along with increased energy requirements from metabolic stress [16]. IC measurements were ordered three times per week for all patients included in this review. To best approximate resting energy expenditure, a dedicated technician performed IC prior to daily interventions. All patients received only EN support and were NPO for the duration of their inclusion in this study. Post-admission alterations in feeding rates occurred in consultation between the RD and burn team based upon trends in measured IC and nitrogen balance.
Table 2 – Patient demographics (n = 37). Male % (n) Agea years (IQR) TBSAa (IQR) Total Full-thickness Ventilator daysa (IQR) Inhalation injury LOS days per %TBSAa (IQR) BMIa (IQR) Height cma (IQR) Weight kga (IQR)
86.5% (32) 44.9 (23.0–56.2) 30 (18.5–47.5) 14.5 (1.0–28.7) 14 (4–28) 10 (27%) 1.40 (0.92–2.9) 28.1 (24.0–32.1) 179 (169–185) 86 (72.5–98.5)
IQR: inter-quartile range. a: median. LOS: length of stay. TBSA: total body surface area.
burns 38 (2012) 645–649
Table 3 – Enteral nutrition outcomes (n = 32). Days to reach 60% of goal Median (IQR) Calorie sources Median % goal (IQR) Enteral feeds IV fluid Days post admission until initial IC Median (IQR)
3 (3.0–4.5)
86% (71.1–100) 14% (0–28.9) 3 (2–6)
IQR: inter-quartile range.
2.3.
Statistical methods
Due to both intra- and inter-patient variation in calorie needs, intake values were analyzed as percent of the measured target goal (HB135 or IC). Documented energy estimates and actual intake were collected and compared to calculate percent of target. Data were analyzed using SPSS 14.0 (SPSS, Chicago, IL) and Stata 11.0 (StataCorp, College Station, TX) software. Median values are reported due to the non-Gaussian distribution of data.
3.
Results
3.1.
Demographics and outcomes (Table 2)
Acute burn admissions during the study period numbered 469, and 37 patients met criteria for inclusion in the analysis. No patients who met the criteria described in the methods section were excluded. Four were between 13 and 18 years old and weighed greater than 45 kg. Five of the thirty-seven patients (13.5%) failed to meet their identified caloric goals within 72 h of admission, resulting in EN commencement. Most study patients were males with large burns and full thickness injury. The median hospital stay per percent TBSA burn was 1.40 days (IQR: 0.92–2.9).
3.2.
Enteral nutrition (Table 3)
Median time to FT placement was 31.1 h (IQR: 23.4–46.5 h) post admission, while median time to initiation of EN was 47.9 h post admission (IQR: 32.3–57.8 h). The median time required for patients to reach 60% of goal was 3 days post-admission (IQR: 3–4.5). While all calories in the first 24 h were from IV infusions, the contribution of IV infusions to total caloric intake diminished over the 1st three days and plateaued near
Fig. 1 – Percent of calories from IV fluid, Day 1–7.
647
20% on post-burn day #4 (Fig. 1). The median time until initial IC was performed was three days post-admission (IQR: 1–10). Documented reasons for failure to reach total daily caloric needs included EN being turned off for procedures or physical therapy and tube loss or obstruction. No study patients were identified as having feeding intolerance.
4.
Discussion
Adequate and timely nutritional support is essential in burn care because of the profound hypermetabolic response to these injuries. Guidelines developed by SCCM and ASPEN help ICU clinicians establish and meet nutritional needs of their patients during the first week of care by addressing initiation of nutritional support in a very detailed manner. We found that our burn center practice for initiation of EN support was generally consistent with the SCCM/ASPEN guidelines [13] and with a recently published multi-national review in mixed ICU populations [17]. The SCCM/ASPEN guidelines recommend that EN be initiated within 24–48 h post admission with feedings advanced toward 50–65% of caloric goal during the two to five days post admission. The practice at our unit was to initiate EN soon after admission in patients who the attending physician expected not be able to meet caloric demands with oral intake. Evaluation of this routine practice demonstrated compliance with median time to initiation of EN just shy of 48 h, and with 60% of goal achieved by 3 days post-admission. At the time of this study, this process was driven entirely at physician discretion. Although our median time to FT placement and commencement of EN were within SCCM/ASPEN guidelines, we identified a concerning time lag between FT insertion and EN commencement. In addition, we had not implemented the SCCM/ASPEN recommendation for use of an enteral nutrition protocol to increase percentage of goal calories provided. The resulting protocol is shown in Appendix A. A future quality improvement project will verify compliance with and efficacy of this protocol. Recently, Mosier et al. demonstrated early EN had no measurable adverse effects and showed possible benefits. A decrease in both hospital length of stay and incidence of wound infection in a population with a mean TBSA of 46% led the authors to recommend the initiation of EN within 24 h post admission [18]. The study also showed 95% of study participants received EN by 48 h, a number that far exceeds our slight majority. Mosier’s work updated that of McDonald et al., who demonstrated early (<1 h post admission) commencement of EN in burn patients with greater than 20% TBSA is safe and effective [19]. One key limitation is that in the design of this project we did not address clinical outcomes and did not collect data regarding possible causes of failure to achieve goal beyond noting that no patients had EN stopped due to feeding intolerance. In addition to recommendations for initiating EN, SCCM/ ASPEN recommend the use of either IC or a predictive equation for the initial nutrition support target. In this study, we used a widely cited standard based on HB as a target until IC was available. Under standard conditions (resting, fasting, nonstressed, thermoneutral environment) IC is equivalent to BEE. Burn patients do not meet these requirements and in the ICU setting IC measures BEE along with increases caused by
648
burns 38 (2012) 645–649
metabolic stress and feeding. Sedation and chemical paralysis, sepsis, ambient temperature, pain, and activity level are all common sources of variation in metabolic demands [20–22]. We routinely adjust EN goals based on IC along with nitrogen balance, laboratory studies and other sources of calories and nutrition. While we recognize the invaluable role SCCM/ASPEN guidelines play in the treatment of the critically ill, these guidelines were not written specifically for burn patients. Indeed, the only burn-specific guidelines state a preference for enteral over parenteral nutrition and that EN be ‘‘initiated as soon as practical’’ [23]. An additional concern in using the SCCM/ASPEN guidelines is their time limitation to the first week post ICU admission; median duration of EN in the study population was 24 days. Patients admitted with large burns – those most likely to benefit from EN – routinely remain hospitalized for weeks or months. Future burn-specific guidelines should address the complexities inherent in providing longer-term nutrition support in critically ill, hypermetabolic patients. Burn patients have variable metabolic requirements during their recovery from injury, and burn-specific guidelines would ideally address appropriate monitoring over this fluctuating metabolic course. This study has several limitations. It is a retrospective review of nutrition care practices at a single regional burn center. The patient population is small and skewed to adult males with larger burns, meaning conclusions based upon these patients may not be broadly applicable. Elderly patients or those with special metabolic needs and smaller burns may have needs for that are not adequately evaluated with this
review. Because the goal was to establish consistency with published guidelines, no outcome-related data was collected during this review and we only present findings from the first week of care. While NS and its correlation to clinical outcomes are commonly addressed in the critical care and burn literature, this was not the purpose of this study. This study did result in quality improvement efforts in nutritional support in our Burn ICU. Although existing practices were largely consistent with SCCM/ASPEN guidelines, potential improvements were identified in time to initiation of enteral nutrition following tube placement and use of a protocol to optimize nutrition management. The resulting protocol for feeding tube placement and enteral feeding initiation addresses the historical delay in initiation of feeding following tube placement. The subsequent impact of the resulting protocol will require evaluation and refinement after an appropriate ramp-in time. Perhaps most importantly, as a result of our experience we would encourage other burn centers to examine quality improvement projects addressing their nutritional practices and would advocate for development of guidelines applicable to the management of patients whose needs for NS extend beyond one week.
Conflict of interest statement None of the authors have any financial or personal relationships that would bias this work. No extramural funding was used in the preparation of this manuscript.
Appendix A
University of Utah Burn Nutrition Support Protocol “A” Criteria Feeding tube should be placed within 24 hours of admission • • • • •
“B” Criteria Calorie count should be initiated at admission and if failing*, FT placed between 72 and 96 hours from admission
>20 percent TBSA burn in adults >10 percent TBSA burn in <12 years or >70 years Known/ suspected inhalaon injury Any significant burn to face TENS or TENS/ SJS overlap (>20% TBSA involvement)
• • • • • •
Nutrition Commencement
•
10 to 20 percent TBSA burn in adults 5 to 10 percent TBSA burn in <12 years or >70 years >5 percent full-thickness burn High voltage injury Circumferenal burn injury Medical problem predisposing to infecon/ poor wound healing (eg, diabetes mellitus, chronic immunosuppression) Paents with demena or developmental delay
Once FT placement is confirmed, begin tube feedings: • • •
For adults, begin Promote® at 20 mL/ hour; increase by 20 mL/ hr every 2 hours to 75mL/ hour or goal as determined by Diecian <30 kg child begin Pediasure® at 20 mL/ hour; increase by 10 mL/ hr every 2 hours to 50mL/ hour or goal as determined by Diecian >30 kg child begin Jevity® at 20 mL/ hour; increase by 10 mL/ hr every 2 hours to 50mL/ hour or goal as determined by Diecian
*Failure is inability to take >60% of caloric needs as PO intake **Indirect Calorimetry performed every M, W, F
Nutrition Maintenance For enteral feeds: • If TF are seen in NG output, hold for 2 hours and restart at previous rate. Discard residual. • If patient has emesis/ abdominal pain, hold tube feeds and notify HO
burns 38 (2012) 645–649
references [13] [1] Goodall M, Stone C, Haynes Jr BW. Urinary output of adrenaline and noradrenaline in severe thermal burns. Ann Surg 1957;145(4):479–87. [2] Farrell K, Bradley S. Estimation of nitrogen requirements in patients with burns. J Burn Care Rehabil 1994;15(2):174. [3] Hart D, Wolf S, Chinkes D, Gore D, Mlcak R, Beauford R. et al. Determinants of skeletal muscle catabolism after severe burn. Ann Surg 2000;232(4):455–65. [4] Saffle JR, Graves C. Nutritional support of the burned patient. In: Herndon D, editor. Total burn care. Philadelphia, PA: W B Saunders Co.; 2007. p. 398–9. [5] Roberts S, Kennerly D, Keane D, George C. Nutrition support in the intensive care: unit adequacy, timelines, and outcomes. Crit Care Nurse 2003;23(6):49–57. [6] Kattelmann K, Hise M, Russel M, Charney P, Stokes M, Compher C. Preliminary evidence for a medical nutrition therapy protocol: enteral feedings for critically ill patients. J Am Diet Assoc 2006;106:1226–41. [7] Saito H, Trocki O, Alexander JW, Kopcha R, Heyd T, Joffe S. The effect of route of nutrient administration on the nutritional state, catabolic hormone secretion, and gut mucosal integrity after burn injury. JPEN 1987;11:1–7. [8] Maejima K, Deitch EA, Berg R. Promotion by burn stress of the translocation of bacteria from the gastrointestinal tracts of mice. Arch Surg 1984;119:166–72. [9] Peng Y, Yuan Z, Xiao G. Effects of early enteral feeding on the prevention of enterogenic infection in severely burned patients. Burns 2001;27:145–9. [10] Williams FN, Jeschke MG, Chinkes DL, Suman OE, Branski LK, Herndon DN. Modulation of the hypermetabolic response to trauma: temperature, nutrition, and drugs. J Am Coll Surg 2009;208(4):489–502. [11] Hise M, Halterman K, Gajewski B. Feeding practices of severely ill intensive care unit patients: an evaluation of energy sources and clinical outcomes. J Am Diet Assoc 2007;107:458–65. [12] De Jonghe B, Appere-De-Vechi C, Fournier M, Tran B, Merrer J, Melchior JC, et al. A prospective survey of nutritional support practices in intensive care unit
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patients: what is prescribed? What is delivered? Crit Care Med 2001;29(1):8–12. Martindale R, McClave S, Vanek V, McCarthy M, Roberts P, Taylor B, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine and American Society for Parenteral and Enteral Nutrition. Crit Care Med 2009;37(9):267–9. Harris JA, Benedict FG. Biometric studies of basal metabolism in man. Washington, DC: Carnegie Institute of Washington; 1919. Saffle JR, Graves C. Nutritional support of the burned patient. In: Herndon D, editor. Total burn care. Philadelphia, PA: W B Saunders Co.; 2007. p. 400. Flancbaum L, Choban P, Sambucco S, Verducci J, Burge JC. Comparison of indirect calorimetry, the Fick method, and prediction equations in estimating the energy requirements of critically ill patients. Am J Clin Nutr 1999;69(3):461–6. Drover J, Cahill N, Kutsogiannis J, Pagliarello G, Wischmeyer P, Wang M, et al. Nutrition therapy for the critically ill surgical patient: we need to do better! J Parenter Enteral Nutr 2010;34(6):644–52. Mosier MJ, Pham TN, Klein MB, Gibran NS, Arnoldo BD, Gamelli RL, et al. Early enteral nutrition in burns: compliance with guidelines and associated outcomes in a multicenter study. J Burn Care Res 2011;32(1):104–9. McDonald WS, Sharp CW, Deitch E. Immediate enteral feeding in burn patients is safe and effective. Ann Surg 1991;213(2):177–83. Caldwell FT. Etiology and control of post burn hypermetabolism: the 1991 presidential address to the American Burn Association. J Burn Care Rehabil 1991;12(5):385–401. Gottschlich MM, Jenkins M, Mayes T, Khoury J, Kagan R, Warden GD. Lack of effect of sleep on energy expenditure and physiologic measures in critically ill burn patients. J Am Diet Assoc 1997;97(2):131–9. Ireton-Jones C, Jones JD. Improved equations for predicting energy expenditure in patients: the Ireton–Jones equations. Nutr Clin Pract 2002;17(1):29–31. American Burn Association. American Burn Association practice guidelines, vol. 22 (2). 2001. p. 59S–66S.
Available online at www.sciencedirect.com
journal homepage: www.elsevier.com/locate/burns
Compliance with nutrition support guidelines in acutely burned patients Brennen Holt, Caran Graves, Iris Faraklas, Amalia Cochran * Burn Center at the University of Utah, United States
article info
abstract
Article history:
Background: Adequate and timely provision of nutritional support is a crucial component of
Accepted 9 December 2011
care of the critically ill burn patient. The goal of this study was to assess a single center’s consistency with Society of Critical Care Medicine/American Society for Parenteral and
Keywords:
Enteral Nutrition (SCCM/ASPEN) guidelines for nutritional support in critically ill patients.
Nutrition
Methods: Acutely burned patients >45 kg in weight admitted to a regional burn center during
Critical illness
a two-year period and who required 5 or more days of full enteral nutritional support were
Burns
eligible for inclusion in this retrospective review. Specific outcomes evaluated include time from admission to feeding tube placement and enteral feeding initiation and percent of nutritional goal received within the first week of hospital stay. Descriptive statistics were used for all analyses. IRB approval was obtained. Results: Thirty-seven patients were included in this retrospective review. Median age of patients was 44.9 years (IQR: 24.2–55.1), and median burn injury size was 30% (IQR: 19–47). Median time to feeding tube placement was 31.1 h post admission (IQR: 23.6–50.2 h), while median time to initiation of EN was 47.9 h post admission (IQR: 32.4–59.9 h). The median time required for patients to reach 60% of caloric goal was 3 days post-admission (IQR: 3–4.5). Conclusion: The median time for initiation of enteral nutrition was within the SCCM/ASPEN guidelines for initial nutrition in the critically ill patient. This project identified a 16 h time lag between placement of enteral access and initiation of enteral nutrition. Development of a protocol for feeding tube placement and enteral nutrition management may optimize early nutritional support in the acutely injured burn patient. # 2012 Elsevier Ltd and ISBI. All rights reserved.
1.
Introduction
Severe burns lead to a hypermetabolic response that is more dramatic than that identified in any other disease or injury [1]. Metabolic rates may exceed 200% of normal, depending on factors that include total body surface area (TBSA) injured, body mass, age, and time from injury to excision of eschar [2,3]. A variety of physiologic processes are thought to cause this hypermetabolic response and the consequences of this complex response can be life threatening. Loss of lean body mass,
decreased immune response, and delayed wound healing are all major manifestations associated with the hypermetabolic response that impact hospital length of stay, morbidity, and mortality. Appropriate and adequate nutrition does play a role in attenuation of this response [4]. Studies have also demonstrated hospital length of stay and morbidity rates increase when adequate nutritional support (NS) is not provided [5,6]. Nutrition support in the critically ill has been shown to help maintain intestinal barrier function [7], prevent bacterial translocation [8], and conserve bowel mucosal integrity [9], further showing that timely provision of NS is a vital
* Corresponding author at: University of Utah, Department of Surgery, 30 North 1900 East, SOM 3B313, Salt Lake City, UT 84132, United States. Tel.: +1 801 581 7508; fax: +1 801 587 9149. E-mail address: [email protected] (A. Cochran). 0305-4179/$36.00 # 2012 Elsevier Ltd and ISBI. All rights reserved. doi:10.1016/j.burns.2011.12.002
646
burns 38 (2012) 645–649
Table 1 – SCCM/ASPEN guidelines evaluated [13]. EN is the preferred route of feeding over parenteral nutrition (PN) for the crtically ill patient who requires nutrition support therapy. Enteral feeding should be started early within the first 24–48 h following admission. The feedings should be advanced toward goal over the next 48–72 h. In the setting of hemodynamic compromise, EN should be withheld until the patient is fully resuscitated and/or stable. The target goal of EN (defined by energy requirements) should be determined and clearly identified at the time of initiation of nutrition support therapy. Energy requirements may be calculated by predictive equations or measured by indirect calorimetry. Efforts to provide >50% to 65% of goal calories should be made to achieve the clinical benefit of EN over the first week of hospitalization. Guidelines in bold are those that were measured for this study.
component of burn care [10]. While multiple studies indicate that ICU patients are often underfed and that care processes may contribute to this, the process of initiation of nutritional support in critically ill burn patients has not been examined [11,12]. Therefore, the primary purpose of this retrospective review is to compare a single center’s enteral nutrition (EN) practices to guidelines published by the Society of Critical Care Medicine (SCCM)/American Society for Parenteral and Enteral Nutrition (ASPEN) [13]. Specifically, we will assess our center’s compliance with identified best practices for feeding tube (FT) placement time, EN start time, and percent of nutritional goal received within the first week of hospital stay (Table 1).
2.
Methods
2.1.
Data collection
This IRB-approved retrospective review included acutely burned pediatric patients who weighed 45 kg or more and adults who were admitted to a regional American Burn Association verified burn center for treatment from January 1, 2007 through December 31, 2008. Patients admitted for non-thermal illness or patients who suffered multisystem trauma in conjunction with their burns were excluded. The institutional data warehouse was used to identify all acutely burned patients who received enteral nutritional support with no oral intake for at least five consecutive days within the first week following admission. Data collected from patient medical records included basic demographics (age and gender), anthropometrics, burn injury characteristics (total and full-thickness TBSA), presence of inhalation injury, time from admission until post-pyloric FT placement, time until EN was started, time until 60% of nutritional goal was achieved, and what percentage of time goal was achieved during Week 1 while receiving EN. Patient hospital length of stay and number of days ventilated were recorded, as were time until initial indirect calorimetry (IC) and any reasons documented for failure to reach feeding goals. Patients who were unable to achieve caloric goals via oral intake within 72 h of admission underwent FT placement and administration of EN. These patients were excluded
from analysis of the length of time from admission to FT placement and time to EN commencement. Calculated total daily caloric value was the sum of intravenous infusions and enteral feeding calories received in 24 h for each day that EN was provided. The published manufacturer’s caloric information for IV infusions and EN were used to calculate the daily caloric amount.
2.2.
Nutrition support
Acute burn patients deemed unlikely to achieve their caloric goals with oral intake alone as assessed by the attending surgeon in consultation with the unit dietician at the time of admission had a FT placed. Per unit standard, FTs were placed under fluoroscopic guidance into the small intestine. Once a FT was in position and the patient was determined by the attending surgeon to have no clinical manifestations of shock, EN was initiated. EN was held for 6 h prior to surgery per anesthesiology directive in non-intubated patients but was not routinely stopped for other procedures nor in intubated patients. ‘‘Catch up’’ feeds when feeds were held for OR or travel were not provided. EN was held until TF placement could be radiographically confirmed for a gastric residual of >200 ml or TF in the NG tube; these same criteria were used to define suspected feeding intolerance. Basal energy expenditure (BEE) was estimated using the Harris–Benedict formula [14], a widely accepted predictive equation. In burn patients, caloric needs have been estimated by multiplying BEE by a factor ranging from 1.2 to 2.0 [15]. In this unit, the Registered Dietitian (RD) calculated the initial caloric goal rate based upon 135% of the Harris–Benedict equation (HB135), and this was used until indirect calorimetry was available. IC, commonly referenced as the gold standard for determining caloric needs in the critically ill, estimates energy expenditure by measuring basal energy needs along with increased energy requirements from metabolic stress [16]. IC measurements were ordered three times per week for all patients included in this review. To best approximate resting energy expenditure, a dedicated technician performed IC prior to daily interventions. All patients received only EN support and were NPO for the duration of their inclusion in this study. Post-admission alterations in feeding rates occurred in consultation between the RD and burn team based upon trends in measured IC and nitrogen balance.
Table 2 – Patient demographics (n = 37). Male % (n) Agea years (IQR) TBSAa (IQR) Total Full-thickness Ventilator daysa (IQR) Inhalation injury LOS days per %TBSAa (IQR) BMIa (IQR) Height cma (IQR) Weight kga (IQR)
86.5% (32) 44.9 (23.0–56.2) 30 (18.5–47.5) 14.5 (1.0–28.7) 14 (4–28) 10 (27%) 1.40 (0.92–2.9) 28.1 (24.0–32.1) 179 (169–185) 86 (72.5–98.5)
IQR: inter-quartile range. a: median. LOS: length of stay. TBSA: total body surface area.
burns 38 (2012) 645–649
Table 3 – Enteral nutrition outcomes (n = 32). Days to reach 60% of goal Median (IQR) Calorie sources Median % goal (IQR) Enteral feeds IV fluid Days post admission until initial IC Median (IQR)
3 (3.0–4.5)
86% (71.1–100) 14% (0–28.9) 3 (2–6)
IQR: inter-quartile range.
2.3.
Statistical methods
Due to both intra- and inter-patient variation in calorie needs, intake values were analyzed as percent of the measured target goal (HB135 or IC). Documented energy estimates and actual intake were collected and compared to calculate percent of target. Data were analyzed using SPSS 14.0 (SPSS, Chicago, IL) and Stata 11.0 (StataCorp, College Station, TX) software. Median values are reported due to the non-Gaussian distribution of data.
3.
Results
3.1.
Demographics and outcomes (Table 2)
Acute burn admissions during the study period numbered 469, and 37 patients met criteria for inclusion in the analysis. No patients who met the criteria described in the methods section were excluded. Four were between 13 and 18 years old and weighed greater than 45 kg. Five of the thirty-seven patients (13.5%) failed to meet their identified caloric goals within 72 h of admission, resulting in EN commencement. Most study patients were males with large burns and full thickness injury. The median hospital stay per percent TBSA burn was 1.40 days (IQR: 0.92–2.9).
3.2.
Enteral nutrition (Table 3)
Median time to FT placement was 31.1 h (IQR: 23.4–46.5 h) post admission, while median time to initiation of EN was 47.9 h post admission (IQR: 32.3–57.8 h). The median time required for patients to reach 60% of goal was 3 days post-admission (IQR: 3–4.5). While all calories in the first 24 h were from IV infusions, the contribution of IV infusions to total caloric intake diminished over the 1st three days and plateaued near
Fig. 1 – Percent of calories from IV fluid, Day 1–7.
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20% on post-burn day #4 (Fig. 1). The median time until initial IC was performed was three days post-admission (IQR: 1–10). Documented reasons for failure to reach total daily caloric needs included EN being turned off for procedures or physical therapy and tube loss or obstruction. No study patients were identified as having feeding intolerance.
4.
Discussion
Adequate and timely nutritional support is essential in burn care because of the profound hypermetabolic response to these injuries. Guidelines developed by SCCM and ASPEN help ICU clinicians establish and meet nutritional needs of their patients during the first week of care by addressing initiation of nutritional support in a very detailed manner. We found that our burn center practice for initiation of EN support was generally consistent with the SCCM/ASPEN guidelines [13] and with a recently published multi-national review in mixed ICU populations [17]. The SCCM/ASPEN guidelines recommend that EN be initiated within 24–48 h post admission with feedings advanced toward 50–65% of caloric goal during the two to five days post admission. The practice at our unit was to initiate EN soon after admission in patients who the attending physician expected not be able to meet caloric demands with oral intake. Evaluation of this routine practice demonstrated compliance with median time to initiation of EN just shy of 48 h, and with 60% of goal achieved by 3 days post-admission. At the time of this study, this process was driven entirely at physician discretion. Although our median time to FT placement and commencement of EN were within SCCM/ASPEN guidelines, we identified a concerning time lag between FT insertion and EN commencement. In addition, we had not implemented the SCCM/ASPEN recommendation for use of an enteral nutrition protocol to increase percentage of goal calories provided. The resulting protocol is shown in Appendix A. A future quality improvement project will verify compliance with and efficacy of this protocol. Recently, Mosier et al. demonstrated early EN had no measurable adverse effects and showed possible benefits. A decrease in both hospital length of stay and incidence of wound infection in a population with a mean TBSA of 46% led the authors to recommend the initiation of EN within 24 h post admission [18]. The study also showed 95% of study participants received EN by 48 h, a number that far exceeds our slight majority. Mosier’s work updated that of McDonald et al., who demonstrated early (<1 h post admission) commencement of EN in burn patients with greater than 20% TBSA is safe and effective [19]. One key limitation is that in the design of this project we did not address clinical outcomes and did not collect data regarding possible causes of failure to achieve goal beyond noting that no patients had EN stopped due to feeding intolerance. In addition to recommendations for initiating EN, SCCM/ ASPEN recommend the use of either IC or a predictive equation for the initial nutrition support target. In this study, we used a widely cited standard based on HB as a target until IC was available. Under standard conditions (resting, fasting, nonstressed, thermoneutral environment) IC is equivalent to BEE. Burn patients do not meet these requirements and in the ICU setting IC measures BEE along with increases caused by
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metabolic stress and feeding. Sedation and chemical paralysis, sepsis, ambient temperature, pain, and activity level are all common sources of variation in metabolic demands [20–22]. We routinely adjust EN goals based on IC along with nitrogen balance, laboratory studies and other sources of calories and nutrition. While we recognize the invaluable role SCCM/ASPEN guidelines play in the treatment of the critically ill, these guidelines were not written specifically for burn patients. Indeed, the only burn-specific guidelines state a preference for enteral over parenteral nutrition and that EN be ‘‘initiated as soon as practical’’ [23]. An additional concern in using the SCCM/ASPEN guidelines is their time limitation to the first week post ICU admission; median duration of EN in the study population was 24 days. Patients admitted with large burns – those most likely to benefit from EN – routinely remain hospitalized for weeks or months. Future burn-specific guidelines should address the complexities inherent in providing longer-term nutrition support in critically ill, hypermetabolic patients. Burn patients have variable metabolic requirements during their recovery from injury, and burn-specific guidelines would ideally address appropriate monitoring over this fluctuating metabolic course. This study has several limitations. It is a retrospective review of nutrition care practices at a single regional burn center. The patient population is small and skewed to adult males with larger burns, meaning conclusions based upon these patients may not be broadly applicable. Elderly patients or those with special metabolic needs and smaller burns may have needs for that are not adequately evaluated with this
review. Because the goal was to establish consistency with published guidelines, no outcome-related data was collected during this review and we only present findings from the first week of care. While NS and its correlation to clinical outcomes are commonly addressed in the critical care and burn literature, this was not the purpose of this study. This study did result in quality improvement efforts in nutritional support in our Burn ICU. Although existing practices were largely consistent with SCCM/ASPEN guidelines, potential improvements were identified in time to initiation of enteral nutrition following tube placement and use of a protocol to optimize nutrition management. The resulting protocol for feeding tube placement and enteral feeding initiation addresses the historical delay in initiation of feeding following tube placement. The subsequent impact of the resulting protocol will require evaluation and refinement after an appropriate ramp-in time. Perhaps most importantly, as a result of our experience we would encourage other burn centers to examine quality improvement projects addressing their nutritional practices and would advocate for development of guidelines applicable to the management of patients whose needs for NS extend beyond one week.
Conflict of interest statement None of the authors have any financial or personal relationships that would bias this work. No extramural funding was used in the preparation of this manuscript.
Appendix A
University of Utah Burn Nutrition Support Protocol “A” Criteria Feeding tube should be placed within 24 hours of admission • • • • •
“B” Criteria Calorie count should be initiated at admission and if failing*, FT placed between 72 and 96 hours from admission
>20 percent TBSA burn in adults >10 percent TBSA burn in <12 years or >70 years Known/ suspected inhalaon injury Any significant burn to face TENS or TENS/ SJS overlap (>20% TBSA involvement)
• • • • • •
Nutrition Commencement
•
10 to 20 percent TBSA burn in adults 5 to 10 percent TBSA burn in <12 years or >70 years >5 percent full-thickness burn High voltage injury Circumferenal burn injury Medical problem predisposing to infecon/ poor wound healing (eg, diabetes mellitus, chronic immunosuppression) Paents with demena or developmental delay
Once FT placement is confirmed, begin tube feedings: • • •
For adults, begin Promote® at 20 mL/ hour; increase by 20 mL/ hr every 2 hours to 75mL/ hour or goal as determined by Diecian <30 kg child begin Pediasure® at 20 mL/ hour; increase by 10 mL/ hr every 2 hours to 50mL/ hour or goal as determined by Diecian >30 kg child begin Jevity® at 20 mL/ hour; increase by 10 mL/ hr every 2 hours to 50mL/ hour or goal as determined by Diecian
*Failure is inability to take >60% of caloric needs as PO intake **Indirect Calorimetry performed every M, W, F
Nutrition Maintenance For enteral feeds: • If TF are seen in NG output, hold for 2 hours and restart at previous rate. Discard residual. • If patient has emesis/ abdominal pain, hold tube feeds and notify HO
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