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Early oral feeding of patients with extensive burns
Burns (1987) 13, (1). 49-52
49
Printed in Great Britain
Early oral feeding of patients with extensive burns* H. J. Klasen and H. J. ten Duis Burn Unit, Roman Catholic Hospital,
Groningen,
Summary The oral administration of fluid to patients with exten-
sive burns is usually acceptable during the first 48 h post-burn. Nutrients can be added to the drinks, whereby a hyperalimentation regimen can be reached within a few days. However, accurate monitoring through laboratory investigations needs to be carried out during
this treatment. INTRODUCTION importance of paying extra attention to the feeding of patients with extensive burns is universally acknowledged, however, it is not an easy task to administer adequate nourishment to these patients. Procedures such tis operations, wound inspections and dressing changes, with or without anaesthetic, threaten to disturb the rhythm of administering food. There is also the tendency to withhold nutrition during the first phase after the burn and to direct most attention to the circulatory problems. The tendency to regard feeding as a secondary aspect is reinforced by symptoms of nausea and vomiting. In some centres a nasogastric tube is inserted routinely in order to empty the stomach contents. In the mid-seventies, Monafo (1970), Caldwell et al. (1971) and Fox and Stanford (1974) suggested treating the threatening circulatory problems with buffered hypertonic saline solution. When our patients were treated with this solution they remained alert and active and did not show any signs of nausea or vomiting. During treatment the patients frequently asked for drinks, which they were allowed to have. Since there were few probTHE
~’Prcscntcd at the Scvcnth International Congress on Burn Injuries. Mclhournc. Australia. Fchruary IWh.
The Netherlands
Iems, the quantities were gradually increased and carbohydrates, fat and protein were added. The advantage of this regimen was that the patients were also personally involved in the treatment and, in a few days, they could receive enough fluids containing carbohydrate. fat and protein that the intravenous infusions could be stopped, even by 48 h in extensively burned patients. Gastrointestinal disturbances, such as diarrhoea, were prevented by gradually increasing the amount of nourishment added to the drinks. The experience gained with this treatment will be discussed below.
METHODS AND MATERIALS Data were collected from 13 patients (6 male, 7 female) with extensive burns who had to meet the following requirements: 16 years of age or older; treatment commenced within 6 h after injury in the Groningen Burn Unit; extent of the burn at least 30 per cent full thickness; no inhalation injuries and no surgery within 48 h of injury; remained alive for at least 1 week. All the patients had burns due to fire, eight had attempted suicide. The average size of the burns was 50 per cent with a range of 30-80 per cent. The average size of the full thickness burns was 45 per cent and varied from 30 to 70 per cent. The average age was 367yr (range lM3y) and the average body weight was 65 kg (range 4678 kg). Four patients died during the course of the treatment. The initial local treatment consisted of silver sulphadiazine cream (1 per cent). The ambient room temperature was 28°C and its relative humidity was 50 per cent. During the presence of members of staff or visitors the room
50
Burns (1987) Vol. 13/No. 1
Table 1. Fluid administration and loss during the first 48 h after injury in 13 patients
with
extensive
deep
burns
Patients
(no.)
% BSA burned
8
30-50
Infusion rate (ml/%/kg body wt)
(223,
Oral intake (ml/%/kg body wt)
Diuresis (ml/h/kg body wt)
(1 .Z.!3,
Insensible loss (ml/%/kg body wt)
,o.G.*,
Increase in body wt (%) 10.8 (7-14%)
r*.z3,
BSA,body surface area Figures in parentheses indicate the range of values. was ventilated by a mass airflow system, providing a total room air exchange 35 times per hour. If the patient was alone in the room the air exchange was reduced to 10 times per hour.
Fluid
management
During the first 48 h the intravenous infusion regimen used buffered hypertonic saline solution consisting of 210 mmol sodium, 60 mmol bicarbonate and 150 mmol chloride per litre. The theoretical infusion rate was 3 ml per percentage burn per kg body weight, equivalent to 0.6 mmol sodium per percentage burn per kg body weight (Fox, 1970). After 24 h albumin solution (20 per cent) was also given, the amount depending on the albumin concentration in the plasma. We aimed at a minimum plasma concentration of 30 g albumin per litre. One of the most important parameters for controlling the rate of fluid infusion was urine production, we aimed at 0.50.7 ml urine per hour per kg body weight. The amounts of fluid given are shown in Table 1. The patients were divided into two groups, one group of eight patients with 30-50 per cent burns (average 40 per cent) and one group of five patients with 60-80 per cent burns (average 68 per cent). The fluids consisted mainly of milk products; extra carbohydrates and protein were added gradually using Fortimel and Nutridrink. The diuresis in the 30-50 per cent burn group was higher than intended. The insensible fluid loss was 26-2.8 ml per percentage burn per kg body weight. The increases in body weight (T~:hlc~ I) were about IO per cent. Trrhk~ II shows the amounts of energy (calories) and protein administered during the first 48 h. The energy input was calculated from the amounts of carbohydrates, fat and protein consumed. the nitrogen/Cal ratio varied between 1:131 and 1:136.
Table II. The oral intake of calories and protein during the first 48 h post-burn in 13 patients with extensive deep burns % BSA burned 6&60 30-50 Total amount of calories Cal/kg body wt Total amount of protein (g) Protein/kg body wt N/Cal ratio
5350
5718
2:
2:;
4 1:131
4 1:136
High blood sugar levels can be expected in patients with extensive burns as a result of the adrenergic reaction. The average level on admission was 13.8 g per cent. The blood sugar levels from the time of admission to the burn unit (2 I h post-burn) and during the lirst 72 h are shown in Figs. 1 and 2. In one patient, with 70 per cent burns, the glucose levels remained high, requiring subsequent treatment with insulin. The blood urea levels during the first 72 h post-burn are shown in Figs. 3 and 4. In all patients with 60-80
blood sugars 30-50%
911 20 -
0
b
I
24
4;
7; h
Fig. 1. Blood sugar levels in eight patients per cent burns during the first 72 h.
with 3&50
51
Klasen and ten Duis: Early oral feeding of burned patients
blood sugars
blood
60-80%
urea 30-50%
mm01 /I 20 -
O
0
24
4;
O b
7; h
Fig. 2. Blood sugarlevelsin five patientswith 60-80 per cent burns during the first 72 h.
2k
7;h
4;
Fig. 3. Blood urea levels in eight patients with 30-50 per cent burns during the first 72 h.
per cent burns the urea levels remained high, but
not apparently due to renal insufficiency. Only showed a low creatinine clearance during the first two days (54 vs. 59 ml/min). In the other patients the creatinine reached high levels.
blood
one patient
DISCUSSION It is almost universal practice to administer intravenous fluids to patients with extensive burns for the treatment of circulatory disturbances. Vari-
ous formulae have been used to estimate the amount of fluid required. Fox (1970) concluded that for the successful treatment of shock, irrespective of the composition and dosage of the infusion fluid, 0.5-0.7 mmol sodium per percentage burn per kg body weight must be administered during the first 48 h following the injury. Following this recommendation, successful attempts were made at treating circulatory disturbances with buffered hypertonic saline solution. This allowed a decrease in the amount of water given and there was less oedema formation. An oral fluid input was avoided to prevent excessive water consumption and the possible induction of gastrointestinal disturbances. It is quite natural for the gastrointestinal tract of a patient with extensive burns to function normally after adequate treatment of the circulatory disturbances or following nursing in a (half) sitting position. Allowing patients oral fluids during the ‘shock’ phase probably means that they will receive more liquid than is strictly necessary and suffer from some oedema. The advantages of drinking are that it makes patients feel more comfortable and also gives them the idea they are personally assisting in their treatment. Drinking also makes it possible to take medicine orally and to receive adequate nourishment within a few
)
urea
60-80%
mm01 II 20-
O Ii
I 21
d8
72 h J
Fig. 4. Blood urea levels in five patients with f&80 cent burns during the first 72 h.
per
days of injury. The disadvantage of putting on extra weight is ‘all part of the bargain’. A point of discussion is what are the benefits of the nourishment in a stressed patient? In a recent article early oral feeding appeared to have a favourable effect on laboratory animals with regard to hypermetabolism (Mochizuki et al., 1984). The favourable effect was probably due to the “preservation of gut mucos:~l integrity and prevention of excessive secretion of catabolic hormones”. Our patients reached a nitrogen/Cal ratio of between 1:131 and 1:136 during the first 48 h, changing later to 1:120. All the patients received nourishment controlled by numerous estimations of their blood sugar levels. Although the first blood sugar levels (+ 1 h post-burn) were high, they dropped within a few hours, with the exception of one patient, in spite of the carbohydrates which were being administered. If the blood sugar values did not drop to normal levels the administration of carbohydrates was decreased or stopped. It was often found that these patients require treatment with insulin subsequently. The urea and creatinine values were also checked regularly, and although they increased to (high)
52
Burns (1987) Vol. 13/No. 1
normal levels, no complications occurred. The high urea levels were not due to renal insufficiency. Further investigations into the effects of early oral feeding in relation to the metabolic consequences certainly seem to he indicated. The fact
that the patients enjoyed the drinks containing calories and protein, and that they became accustomed to receiving oral fluids within 48 h so that their intravenous infusion could be ended, is considered to be very advantageous.
Fox C. L. (1970) Evaluation of various salt solutions. In: Matter P., Barclay T. L. and Konckova Z. (eds), Research in Burns. Bern: Hans Huber, p. 67. Fox C. L. and Stanford J. W. (1974) Comparative efficacy of hypo-, iso-, and hypertonic sodium solutions in experimental burn shock. Surgery 75,71. Mochizuki H., Trocki 0.. Dominioni L. et al. (1984) Mechanism of prevention of postburn hypermetabolism and catabolism by early enteral feeding. Ann. Surg. 200, 297. Monafo W. W. (1970) The treatment of burn shock by intravenous and oral administration of hypertonic lactated saline solutions. J. Trauma 10, 575.
REFERENCES Caldwell F. T., Casali R. E., Flanigan W. J. et al. (1971) What constitutes the proper solution for resuscitation of the severely burned patients? Am. J. Surg.
122, 655.
Paper accepted 26 July 1986.
49
Printed in Great Britain
Early oral feeding of patients with extensive burns* H. J. Klasen and H. J. ten Duis Burn Unit, Roman Catholic Hospital,
Groningen,
Summary The oral administration of fluid to patients with exten-
sive burns is usually acceptable during the first 48 h post-burn. Nutrients can be added to the drinks, whereby a hyperalimentation regimen can be reached within a few days. However, accurate monitoring through laboratory investigations needs to be carried out during
this treatment. INTRODUCTION importance of paying extra attention to the feeding of patients with extensive burns is universally acknowledged, however, it is not an easy task to administer adequate nourishment to these patients. Procedures such tis operations, wound inspections and dressing changes, with or without anaesthetic, threaten to disturb the rhythm of administering food. There is also the tendency to withhold nutrition during the first phase after the burn and to direct most attention to the circulatory problems. The tendency to regard feeding as a secondary aspect is reinforced by symptoms of nausea and vomiting. In some centres a nasogastric tube is inserted routinely in order to empty the stomach contents. In the mid-seventies, Monafo (1970), Caldwell et al. (1971) and Fox and Stanford (1974) suggested treating the threatening circulatory problems with buffered hypertonic saline solution. When our patients were treated with this solution they remained alert and active and did not show any signs of nausea or vomiting. During treatment the patients frequently asked for drinks, which they were allowed to have. Since there were few probTHE
~’Prcscntcd at the Scvcnth International Congress on Burn Injuries. Mclhournc. Australia. Fchruary IWh.
The Netherlands
Iems, the quantities were gradually increased and carbohydrates, fat and protein were added. The advantage of this regimen was that the patients were also personally involved in the treatment and, in a few days, they could receive enough fluids containing carbohydrate. fat and protein that the intravenous infusions could be stopped, even by 48 h in extensively burned patients. Gastrointestinal disturbances, such as diarrhoea, were prevented by gradually increasing the amount of nourishment added to the drinks. The experience gained with this treatment will be discussed below.
METHODS AND MATERIALS Data were collected from 13 patients (6 male, 7 female) with extensive burns who had to meet the following requirements: 16 years of age or older; treatment commenced within 6 h after injury in the Groningen Burn Unit; extent of the burn at least 30 per cent full thickness; no inhalation injuries and no surgery within 48 h of injury; remained alive for at least 1 week. All the patients had burns due to fire, eight had attempted suicide. The average size of the burns was 50 per cent with a range of 30-80 per cent. The average size of the full thickness burns was 45 per cent and varied from 30 to 70 per cent. The average age was 367yr (range lM3y) and the average body weight was 65 kg (range 4678 kg). Four patients died during the course of the treatment. The initial local treatment consisted of silver sulphadiazine cream (1 per cent). The ambient room temperature was 28°C and its relative humidity was 50 per cent. During the presence of members of staff or visitors the room
50
Burns (1987) Vol. 13/No. 1
Table 1. Fluid administration and loss during the first 48 h after injury in 13 patients
with
extensive
deep
burns
Patients
(no.)
% BSA burned
8
30-50
Infusion rate (ml/%/kg body wt)
(223,
Oral intake (ml/%/kg body wt)
Diuresis (ml/h/kg body wt)
(1 .Z.!3,
Insensible loss (ml/%/kg body wt)
,o.G.*,
Increase in body wt (%) 10.8 (7-14%)
r*.z3,
BSA,body surface area Figures in parentheses indicate the range of values. was ventilated by a mass airflow system, providing a total room air exchange 35 times per hour. If the patient was alone in the room the air exchange was reduced to 10 times per hour.
Fluid
management
During the first 48 h the intravenous infusion regimen used buffered hypertonic saline solution consisting of 210 mmol sodium, 60 mmol bicarbonate and 150 mmol chloride per litre. The theoretical infusion rate was 3 ml per percentage burn per kg body weight, equivalent to 0.6 mmol sodium per percentage burn per kg body weight (Fox, 1970). After 24 h albumin solution (20 per cent) was also given, the amount depending on the albumin concentration in the plasma. We aimed at a minimum plasma concentration of 30 g albumin per litre. One of the most important parameters for controlling the rate of fluid infusion was urine production, we aimed at 0.50.7 ml urine per hour per kg body weight. The amounts of fluid given are shown in Table 1. The patients were divided into two groups, one group of eight patients with 30-50 per cent burns (average 40 per cent) and one group of five patients with 60-80 per cent burns (average 68 per cent). The fluids consisted mainly of milk products; extra carbohydrates and protein were added gradually using Fortimel and Nutridrink. The diuresis in the 30-50 per cent burn group was higher than intended. The insensible fluid loss was 26-2.8 ml per percentage burn per kg body weight. The increases in body weight (T~:hlc~ I) were about IO per cent. Trrhk~ II shows the amounts of energy (calories) and protein administered during the first 48 h. The energy input was calculated from the amounts of carbohydrates, fat and protein consumed. the nitrogen/Cal ratio varied between 1:131 and 1:136.
Table II. The oral intake of calories and protein during the first 48 h post-burn in 13 patients with extensive deep burns % BSA burned 6&60 30-50 Total amount of calories Cal/kg body wt Total amount of protein (g) Protein/kg body wt N/Cal ratio
5350
5718
2:
2:;
4 1:131
4 1:136
High blood sugar levels can be expected in patients with extensive burns as a result of the adrenergic reaction. The average level on admission was 13.8 g per cent. The blood sugar levels from the time of admission to the burn unit (2 I h post-burn) and during the lirst 72 h are shown in Figs. 1 and 2. In one patient, with 70 per cent burns, the glucose levels remained high, requiring subsequent treatment with insulin. The blood urea levels during the first 72 h post-burn are shown in Figs. 3 and 4. In all patients with 60-80
blood sugars 30-50%
911 20 -
0
b
I
24
4;
7; h
Fig. 1. Blood sugar levels in eight patients per cent burns during the first 72 h.
with 3&50
51
Klasen and ten Duis: Early oral feeding of burned patients
blood sugars
blood
60-80%
urea 30-50%
mm01 /I 20 -
O
0
24
4;
O b
7; h
Fig. 2. Blood sugarlevelsin five patientswith 60-80 per cent burns during the first 72 h.
2k
7;h
4;
Fig. 3. Blood urea levels in eight patients with 30-50 per cent burns during the first 72 h.
per cent burns the urea levels remained high, but
not apparently due to renal insufficiency. Only showed a low creatinine clearance during the first two days (54 vs. 59 ml/min). In the other patients the creatinine reached high levels.
blood
one patient
DISCUSSION It is almost universal practice to administer intravenous fluids to patients with extensive burns for the treatment of circulatory disturbances. Vari-
ous formulae have been used to estimate the amount of fluid required. Fox (1970) concluded that for the successful treatment of shock, irrespective of the composition and dosage of the infusion fluid, 0.5-0.7 mmol sodium per percentage burn per kg body weight must be administered during the first 48 h following the injury. Following this recommendation, successful attempts were made at treating circulatory disturbances with buffered hypertonic saline solution. This allowed a decrease in the amount of water given and there was less oedema formation. An oral fluid input was avoided to prevent excessive water consumption and the possible induction of gastrointestinal disturbances. It is quite natural for the gastrointestinal tract of a patient with extensive burns to function normally after adequate treatment of the circulatory disturbances or following nursing in a (half) sitting position. Allowing patients oral fluids during the ‘shock’ phase probably means that they will receive more liquid than is strictly necessary and suffer from some oedema. The advantages of drinking are that it makes patients feel more comfortable and also gives them the idea they are personally assisting in their treatment. Drinking also makes it possible to take medicine orally and to receive adequate nourishment within a few
)
urea
60-80%
mm01 II 20-
O Ii
I 21
d8
72 h J
Fig. 4. Blood urea levels in five patients with f&80 cent burns during the first 72 h.
per
days of injury. The disadvantage of putting on extra weight is ‘all part of the bargain’. A point of discussion is what are the benefits of the nourishment in a stressed patient? In a recent article early oral feeding appeared to have a favourable effect on laboratory animals with regard to hypermetabolism (Mochizuki et al., 1984). The favourable effect was probably due to the “preservation of gut mucos:~l integrity and prevention of excessive secretion of catabolic hormones”. Our patients reached a nitrogen/Cal ratio of between 1:131 and 1:136 during the first 48 h, changing later to 1:120. All the patients received nourishment controlled by numerous estimations of their blood sugar levels. Although the first blood sugar levels (+ 1 h post-burn) were high, they dropped within a few hours, with the exception of one patient, in spite of the carbohydrates which were being administered. If the blood sugar values did not drop to normal levels the administration of carbohydrates was decreased or stopped. It was often found that these patients require treatment with insulin subsequently. The urea and creatinine values were also checked regularly, and although they increased to (high)
52
Burns (1987) Vol. 13/No. 1
normal levels, no complications occurred. The high urea levels were not due to renal insufficiency. Further investigations into the effects of early oral feeding in relation to the metabolic consequences certainly seem to he indicated. The fact
that the patients enjoyed the drinks containing calories and protein, and that they became accustomed to receiving oral fluids within 48 h so that their intravenous infusion could be ended, is considered to be very advantageous.
Fox C. L. (1970) Evaluation of various salt solutions. In: Matter P., Barclay T. L. and Konckova Z. (eds), Research in Burns. Bern: Hans Huber, p. 67. Fox C. L. and Stanford J. W. (1974) Comparative efficacy of hypo-, iso-, and hypertonic sodium solutions in experimental burn shock. Surgery 75,71. Mochizuki H., Trocki 0.. Dominioni L. et al. (1984) Mechanism of prevention of postburn hypermetabolism and catabolism by early enteral feeding. Ann. Surg. 200, 297. Monafo W. W. (1970) The treatment of burn shock by intravenous and oral administration of hypertonic lactated saline solutions. J. Trauma 10, 575.
REFERENCES Caldwell F. T., Casali R. E., Flanigan W. J. et al. (1971) What constitutes the proper solution for resuscitation of the severely burned patients? Am. J. Surg.
122, 655.
Paper accepted 26 July 1986.