The effect of a hydrolyzed collagen-based supplement on wound healing in patients with burn: A randomized double-blind pilot clinical trial.

INTRODUCTION: Burn is among the most severe forms of critical illness, associated with extensive and prolonged physical, metabolic and mental disorders. The aim of this study was to assess the effect of an oral, low-cost, and accessible collagen-based supplement on wound healing in patients with burn. METHODS: In this randomized double-blind controlled pilot clinical trial, 31 men, 18-60years, with 20-30% total body surface area burn were studied. Patients were randomly assigned to receive either a collagen-based supplement (1000kcal) or an isocaloric placebo, for 4 weeks. Serum pre-albumin, rate of wound healing, length of hospital stay, and anthropometries were assessed at baseline, and the end of week 2 and 4. RESULTS: Serum pre-albumin was significantly higher at week 2 (29.7±13.6 vs. 17.8±7.5mg/dL, P=0.006) and week 4 (35.1±7.6 vs. 28.3±8.2mg/dL, P=0.023) in collagen than control group. Changes in pre-albumin concentration were also significantly higher in collagen group at week 2 (13.9±9.8 vs. -1.9±10.3mg/dL, P<0.001) and week 4 (19.2±7.5 vs. 8.5±10.1mg/dL, P=0.002). The Hazard ratio of wound healing was 3.7 times in collagen compared to control group (95% CI: 1.434-9.519, P=0.007). Hospital stay was clinically, but not statistically, lower in collagen than control group (9.4±4.6 vs. 13.5±7 days, P=0.063). There were no significant differences in weight, body mass index, dietary energy and protein intakes between the two groups. CONCLUSION: The findings showed that a hydrolyzed collagen-based supplement could significantly improve wound healing and circulating pre-albumin, and clinically reduce hospital stay in patients with 20-30% burn.

Comparing isolated soy protein with flaxseed oil vs isolated soy protein with corn oil and wheat flour with corn oil consumption on muscle catabolism, liver function, blood lipid, and sugar in burn patients: a randomized clinical trial.

BACKGROUND: There is controversy regarding whether increasing isolated soy protein (ISP) with or without flaxseed oil (FO), as functional foods, would lead to reduce muscle catabolism and cachexia in burn patients. METHODS: One hundred and eighty-eight patients were assessed for eligibility in this randomized controlled trial. Of these, seventy-three eligible patients (total burn surface area 20-50%) were randomly assigned to three groups, labeled as Control (wheat flour [WF] + corn oil [CO]), ISP + FO, and ISP + CO, to receive these nutrients for three weeks. Weight, body mass index (BMI), serum hepatic enzymes (alanine transaminase [ALT], aspartate transaminase [AST], alkaline phosphatase [ALP]), systemic inflammatory response syndrome (SIRS), 24-h urinary urea nitrogen excretion (UUN), serum creatinine, 24-h urinary creatinine (UUC) excretion, fasting blood sugar (FBS), triglyceride (TG), and cholesterol were measured. RESULTS: Using analysis of covariance models in the intention-to-treat population (n = 73), we found that at three weeks, patients in the ISP groups had lost significantly less in weight and BMI compared to those in the control group (all P < 0.01). Nitrogen retention and serum creatinine (primary outcomes) increased significantly in the ISP groups compared with the control group. Even after controlling for potential covariates in ANCOVA models, changes in these indices were still statistically significant (P = 0.008 and P = 0.005 for nitrogen balance and serum creatinine, respectively). However, no such significant differences were found between the ISP groups. On the other hand, 24-h UUN, and UUC excretion, serum hepatic enzymes, FBS, TG, and cholesterol were not significant between the groups (P > 0.05). CONCLUSION: ISP and FO compared to WF and CO reduced muscle catabolism and increased body weight in burn patients. TRIAL REGISTRATION: Iranian Registry of Clinical Trials, IRCT2014051817740N1 . Registered on 27 June 2014.

Propranolol como nueva estrategia no nutricional para reducir el catabolismo en el paciente quemado crítico: ¿dónde estamos? ¿hacia dónde vamos? / No disponible

No disponible

Recomendação de arginina na terapia nutricional de pacientes queimados: aspectos atuais / Recommendation of arginine in the nutritional therapy of burned patients: current aspects / Recomendación de la arginina en la terapia nutricional de los pacientes quemados: aspectos actuales

Objetivo: Identificar se existe um padrão de recomendação de arginina para terapia nutricional de pacientes queimados, a partir de revisão integrativa da literatura. Método: Realizou-se uma revisão integrativa da literatura, com busca nos artigos on-line indexados na Biblioteca Virtual em Saúde (BVS) e no Google Acadêmico, no período entre janeiro de 2011 e julho de 2017, publicados em português, inglês e espanhol. Os resultados foram apresentados em quadros. Resultados: No total, foram encontrados 112 artigos, sendo que apenas seis foram adequados ao critério de inclusão do estudo. Em cinco, que foram lidos e analisados, a quantidade de suplementação recomendada de arginina foi a mesma, sendo de 17g/dia; e um foi acima de 12g/dia. Além disso, esses mesmos autores concordaram que a quantidade adequada de suplementação com arginina, tempo de uso, método de administração e nível de segurança ainda não estão bem estabelecidos como rotina de uso em pacientes com grandes queimaduras. Conclusões: Mesmo sendo a arginina considerada um aminoácido condicionalmente essencial e muito importante no processo de cicatrização em pacientes queimados, ainda são necessários mais estudos clínicos para especificar a dose propícia para a terapia nutricional segura e eficaz com arginina em paciente queimados.

Objective: To identify whether there is a standard of arginine recommendation for nutritional therapy of burned patients, from the integrative review of the literature. Methods: An integrative revision of the literature was conducted, searching for articles on line indexed in the Virtual Health Library (BVS) and Google scholar, in the period from January of 2011 to July 2017, published in portuguese, english and spanish. The results were presented in paintings. Results: In total, 112 articles were found, and only six were suitable for the inclusion criterion of the study. In five, of which were read and analyzed, the quantity of recommended supplementation of arginine was the same, being of 17g/day; and one was above 12g/day. Moreover, these same authors agreed that the appropriate amount of supplementation with arginine, time of use, method of administration and security level are not yet well established as routine of use in patients with large burns. Conclusions: Even though arginine is considered a conditionally essential amino acid and is very important in the healing process in burnt patients, more clinical studies are still necessary to specify the correct dose for safe and effective nutritional therapy with arginine in a burnt patient.

Objectivo: Identificar si hay un estándar de la recomendación de la arginina para la terapia alimenticia de pacientes quemados, a partir de una revisión integradora de la literatura. Método: Se realizó una revisión integradora de la literatura, buscando artículos on-line indexados en la biblioteca virtual de salud (BVS) y Google Scholar, en el período de enero de 2011 a julio de 2017, publicados en portugués, inglés y español. Los resultados fueron presentados en cuadros. Resultados: En total, se encontraron 112 artículos, y sólo seis fueron apropiados para el criterio de inclusión del estudio. En cinco de los que estudios analisados, la cantidad de suplementación recomendada de arginina era la misma, siendo de 17g/día; y uno recomendaba cantidad superior a 12g/dia. Además, estos mismos autores convinieron que la cantidad apropiada de la suplementación con arginina, tiempo de uso, método de administración y nivel de seguridad no estén pero bien establecidas como rutina para el uso en pacientes con grandes quemaduras. Conclusiones: A pesar de arginina considerada un aminoácido condicionalmente esencial y es muy importante en el proceso de la cicatrización de heridas en pacientes quemados, aún son necesarios más estudios clínicos que especifiquen la dosis segura y efectiva terapia nutricional con arginina en pacientes quemados.

The effects of frenotomy on breastfeeding

Although the interference of tongue-tie with breastfeeding is a controversial subject, The use of lingual frenotomy has been widely indicated by health professionals. Objective : To observe changes in breastfeeding patterns after lingual frenotomy concerning the number of sucks, pause length between groups of sucking and mother's complaints. Material and Methods : Oral yes/no questions about breastfeeding symptoms and sucking/swallowing/breathing coordination were answered by the mothers of 109, 30 day old infants. On the same day the infants had their lingual frenulum assessed by administering a lingual frenulum protocol. After the assessment, all tongue-tied infants were referred for frenotomy; nevertheless, only 14 underwent the surgery. Of the 109 infants, 14 infants who did not have frenulum alterations were included as controls. Birth order and gender were the criteria for recruiting the control group. The tongue-tied infants underwent lingual frenotomy at 45 days of age. At the conclusion of the frenotomy, the infants were breastfed. At 75 days old, both groups – control and post-frenotomy – were reassessed. Before the reassessment the same oral yes/no questions were answered by the mothers of the 14 infants who underwent frenotomy. The mothers of the control group answered the questionnaire only at the time of the first assessment. Data were subjected to statistical analysis. Results : After frenotomy, the number of sucks increased and the pause length between sucking decreased during breastfeeding. The controls maintained the same patterns observed in the first assessment. From the questionnaire answered by the mothers of the 14 tongue-tied infants, at 30 days and 75 days, we observed that the symptoms concerning breastfeeding and sucking/swallowing/breathing coordination were improved after lingual frenotomy Conclusions : after lingual frenotomy, changes were observed in the breastfeeding patterns of the the tongue-tied ...

Effect of oral olive oil on healing of 10-20% total body surface area burn wounds in hospitalized patients.

The purpose of this study was to evaluate the effect of consumption of oral olive oil on clinical outcomes and wound healing of thermally injured patients with hospital stays. One hundred patients (mean age; 33.34±7 years) with 10-20% total body surface area, deep second degree and more burn wounds were randomized to receive either oral olive oil or sunflower oil as the oil in their diet. Patients were evaluated daily for occurrence of wound infection, sepsis and healing of the grafted skin. Also the duration of hospitalization and admission to the intensive care unit were compared in two groups. Results showed that there was no significant difference between the olive oil group and the control group in percent of TBSA involvement (14.28±0.53 vs. 13.02±0.48, P=0.7), albumin concentration (3.25±0.5 vs. 3.13±0.5, P=0.5) and mean calorie intake (2034±216.9 kcal vs2118±192.1 kcal, P=0.2). We found a significant difference in the duration of wound healing (7.2±0.5 vs. 8.7±0.5, P=0.04) and duration of hospitalization (7.4±0.5 vs. 8.9±0.4, P=0.05) in the olive oil group versus the control group. We did not find any difference in ICU admission, wound infection and occurrence of sepsis between two groups. This study showed that an oral diet provided with olive oil in patients with burn may accelerate wound healing and decrease the duration of hospitalization.

Nutritional care of the obese adult burn patient: a U.K. Survey and literature review.

Obesity is an emerging healthcare problem and affects an increasing number of burn patients worldwide. An email survey questionnaire was constructed and distributed among the 16 U.K. burn services providing adult inpatient facilities to investigate nutritional practices in obese thermally injured patients. Responses received from all dieticians invited to participate in the study were analyzed, and a relevant literature review of key aspects of nutritional care is presented. The majority of services believe that obese patients warrant a different nutritional approach with specific emphasis to avoid overfeeding. The most common algebraic formulae used to calculate calorific requirements include the Schofield, Henry, and modified Penn State equations. Indirect calorimetry despite being considered the "criterion standard" tool to calculate energy requirements is not currently used by any of the U.K. burn services. Gastric/enteral nutrition is initiated within 24 hours of admission in the services surveyed, and a variety of different practices were noted in terms of fasting protocols before procedures requiring general anesthesia/sedation. Hypocaloric regimens for obese patients are not supported by the majority of U.K. facilities, given the limited evidence base supporting their use. The results of this survey outline the wide diversity of dietetic practices adopted in the care of obese burn patients and reveal the need for further study to determine optimal nutritional strategies.

ESPEN endorsed recommendations: nutritional therapy in major burns.

BACKGROUND & AIMS: Nutrition therapy is a cornerstone of burn care from the early resuscitation phase until the end of rehabilitation. While several aspects of nutrition therapy are similar in major burns and other critical care conditions, the patho-physiology of burn injury with its major endocrine, inflammatory, metabolic and immune alterations requires some specific nutritional interventions. The present text developed by the French speaking societies, is updated to provide evidenced-based recommendations for clinical practice. METHODS: A group of burn specialists used the GRADE methodology (Grade of Recommendation, Assessment, Development and Evaluation) to evaluate human burn clinical trials between 1979 and 2011. The resulting recommendations, strong suggestions or suggestions were then rated by the non-burn specialized experts according to their agreement (strong, moderate or weak). RESULTS: Eight major recommendations were made. Strong recommendations were made regarding, 1) early enteral feeding, 2) the elevated protein requirements (1.5-2 g/kg in adults, 3 g/kg in children), 3) the limitation of glucose delivery to a maximum of 55% of energy and 5 mg/kg/h associated with moderate blood glucose (target ≤ 8 mmol/l) control by means of continuous infusion, 4) to associated trace element and vitamin substitution early on, and 5) to use non-nutritional strategies to attenuate hypermetabolism by pharmacological (propranolol, oxandrolone) and physical tools (early surgery and thermo-neutral room) during the first weeks after injury. Suggestion were made in absence of indirect calorimetry, to use of the Toronto equation (Schoffield in children) for energy requirement determination (risk of overfeeding), and to maintain fat administration ≤ 30% of total energy delivery. CONCLUSION: The nutritional therapy in major burns has evidence-based specificities that contribute to improve clinical outcome.

Guidelines for specialized nutritional and metabolic support in the critically-ill patient. Update. Consensus SEMICYUC-SENPE: Critically-ill burnt patient / Recomendaciones para el soporte nutricional y metabólico especializado del paciente crítico. Actualización. Consenso SEMICYUC-SENPE: Paciente quemado crítico

The response to severe burns is characterized by hypermetabolism (the most hypermetabolic existing model of aggression) and hypercatabolism, with a high degree of destruction of the skeletal musculature. Metabolic disorders are most evident in the first two weeks after the burn, although they can be prolonged in direct relation to the complications that these patients develop. Nutritional-metabolic support is an essential part of the treatment of these patients and should be started early, preferentially through the enteral route, with parenteral nutrition as complementary support. Exact calculation of calorie-protein requirements in these patients is difficult, even when indirect calorimetry is used, due to the high loss of proteins and CO2through the skin. Specific pharmaco nutrients are indicated, with a high dose of micronutrients. The use of drugs or medications with anabolic effects is also sometimes indicated (AU)

La respuesta que se objetiva tras una agresión térmica grave se caracteriza por hipermetabolismo (es el modelo de agresión más hipermetabólica que existe) e hipercatabolismo, con una elevada destrucción de la musculatura esquelética. Los trastornos metabólicos son más evidentes en las 2 primeras semanas tras la quemadura, aunque pueden prolongarse en relación directa con las complicaciones aparecidas. El soporte nutro metabólico forma parte indiscutible del tratamiento de estos pacientes y debe ser precoz, utilizando preferentemente la vía enteral y la nutrición parenteral complementaria. Es dificultoso el cálculo exacto de los requerimientos calórico proteicos, aun empleando calorimetría indirecta, debido a las elevadas pérdidas cutáneas de proteínas y Co2. Cabe destacar la indicación de farmaconutrientes específicos, de dosis elevadas de micronutrientes y, en algunas situaciones, del empleo de medicaciones o fármacos con efectos anabólicos (AU)

Update on the critical care management of severe burns.

Care of the severely injured patient with burn requires correct diagnosis, appropriately tailored resuscitation, and definitive surgical management to reduce morbidity and mortality. Currently, mortality rates related to severe burn injuries continue to steadily decline due to the standardization of a multidisciplinary approach instituted at tertiary health care centers. Prompt and accurate diagnoses of burn wounds utilizing Lund-Browder diagrams allow for appropriate operative and nonoperative management. Coupled with diagnostic improvements, advances in resuscitation strategies involving rates, volumes, and fluid types have yielded demonstrable benefits related to all aspects of burn care. More recently, identification of comorbid conditions such as inhalation injury and malnutrition have produced appropriate protocols that aid the healing process in severely injured patients with burn. As more patients survive larger burn injuries, the early diagnosis and successful treatment of secondary and tertiary complications are becoming commonplace. While advances in this area are exciting, much work to elucidate immune pathways, diagnostic tests, and effective treatment regimens still remain. This review will provide an update on the critical care management of severe burns, touching on accurate diagnosis, resuscitation, and acute management of this difficult patient population.

The use of immunonutrition in burn injury care: where are we?

The aim of this study is to review the current evidence for immunonutrition use in patients with burn injury. Nutrients of interest included glutamine, arginine, and omega-3 fatty acids (fish oil). A literature review was conducted to identify studies that evaluated the use of immunonutrients in pediatric and adult patients with burn injury. Search terms included burns, immunonutrition, pharmaconutrition, glutamine, arginine, omega-3, and fish oil. Glutamine: Nine randomized controlled trials (four represented in abstract only) investigating enteral supplementation and two trials investigating parenteral supplementation of glutamine were identified. Arginine: Five trials investigating the effect of arginine supplementation were identified (three represented in abstract only). Omega-3 fatty acids: Three studies investigating the effect of enteral fish oil supplementation were identified (one represented in abstract only). Combined immunonutrients: Six studies were identified that investigated immunonutrients as a combination of active dietary constituents (rather than as individual nutrients). Despite the semiessential nature of arginine after burn injury, there were surprisingly little data regarding nutritional supplementation. Literature around supplementation of omega-3 fatty acids is found to be lacking in the burn injury population. The combination of immunonutrients as a component of enteral formulae limits identification of the active nutrient and ideal dosage. Current evidence supports the use of enteral glutamine supplementation for patients with severe burn injuries. Questions remain regarding dosage, timing, and length of supplementation.

n-3 Fatty acid supplementation in burned paediatric patients.

AIM: To determine the effect of dietary supplementation with n-3 fatty acids (FA) in paediatric burned patients who had less than 20% of total body surface affected. METHODS: Burned patients were randomly assigned into two groups, one of them received a supplement of n-3 FA during 5 weeks; the other group was considered as not n-3 supplemented burned group. A third group of no burned patients was selected as control. Blood samples were collected at admission and in burned groups at the final of the study. Plasma and erythrocyte phospholipid FA composition and some biochemical parameters related to the clinical evolution: total plasma proteins and C3 and C4 complement proteins were determined. RESULTS: In the early post-burn patients, there is an increase in saturated and monounsaturated FAs in plasma phospholipids, and a decrease in polyunsaturated FAs compared with control. These alterations are in favour of proinflammatory response to burn injury. In n-3 FA supplemented group, these changes were further reverted, and a favourable response in the amount of total plasma proteins and in C3 and C4 proteins of the complement system was demonstrated. CONCLUSION: Dietary n-3 FA supplementation might be beneficial for patients suffering thermal injury.

Abordagem nutricional em um paciente pediátrico gravemente queimado: relato de caso / Case Report: Nutritional Approach in a Seriously Burned Pediatric Patient

A terapia nutricional exerce função importante na recuperação do pacientequeimado, sendo fator determinante para evolução clínica. O presente estudo trata-se de um relato de caso realizado com uma criança internada em fevereiro de 2009 na Unidade de Queimados do Hospital Regional da Asa Norte do Distrito Federal, apresentando 40 por cento de Superfície Corporal Queimada por álcool, cujo objetivo foi relatar ediscutir a eficácia da conduta nutricional em uma criança gravemente queimada. A avaliação nutricional foi realizada logo após a admissão hospitalar e a dietoterapia iniciada precocemente, ou seja, nas primeiras 24 horas por via oral, tendo sido associada à nutrição enteral via sonda nasogástrica no segundo dia de internação hospitalar. Foram ofertadas, em média, 2.700 kcal/dia e 114 g de proteína/dia. Embora o paciente tenha apresentado aceitação de 50 por cento dieta via oral, 80 por cento das necessidades nutricionais foram atingidas por meio das duas vias de administração da terapia nutricional. No decorrer da internação evidenciou-se perda ponderal de 4,7 kg, fato comumente encontrado devido a regressão do edema, ao hipermetabolismo e ipercatabolismo desencadeados pelafisiopatologia da queimadura. Observou-se que a terapia nutricional instituída precocemente pode atenuar os efeitos metabólicos e a perda de peso acentuada, por fornecer os nutrientes que normalmente seriam depletados das reservas do indivíduo, além de auxiliar o processo de cicatrização, minimizar a resposta inflamatória e reduzir as intervenções cirúrgicas e o tempo de internação hospitalar.

Nutritional therapy has an important role in the recovery of burned patients, as a determinant factor for the clinical outcome. This study is a case report regarding a child hospitalized in February 2009 at the Burns Unit of the Hospital Regional da Asa Norte, in the Federal District, Brazil, who presented a burn size of 40 percent of body-surface area by alcohol, which aims to report and discuss the effectiveness of the nutritional intervention in a child seriously burned. Nutritional assessmentwas performed shortly after hospital admission and dietotherapy startedearly, orally, within the first 24 hours, and was associated with enteral nutrition via nasogastric tube on the 2nd day of hospitalization. An average of 2700 kcal and 114 g protein were offered daily. Although the patient presented 50 percent of acceptance of oral diet, 80 percent of the nutritional needs were met through the two routes of administration of nutritional therapy. During the hospitalization period a ponderal loss of 4.7 kg was observed, a fact commonly found due to regression of edema, hypercatabolism and hypermetabolism caused by the physiopathology of the burn. It was noticed that early institution of nutrition therapy can reduce the metabolic effects and accentuated weight loss, by providing the nutrients that would normally be depleted from the individual stock, besides assisting the cicatrization process, minimizes the inflammatoryresponse and reduce surgical and hospital stay.

The effect of Lactobacillus bacteria supplement on sepsis and its complications in patients with acute burns.

Sepsis as a result of bacterial translocation from the gastrointestinal tract (GIT) is a known associate of morbidity and mortality in patients with severe burns. This translocation is influenced by the GIT flora. Oral consumption of Lactobacillus bacteria was previously shown to reduce translocation. We conducted a retrospective cohort study on a series of 56 patients with burns admitted to Soroka University Medical Center in Beer-Sheva, Israel. Those 56 patients included 28 who were given lactobacillus supplements and 28 who were not. The parameters that were compared between the groups evaluated the level of sepsis and its complications. The parameters of morbidity during hospitalization were significantly higher in the treatment group; however, their mortality was lower. That difference in mortality between the groups was not significant as a whole (p=0.071), but it was significant in the subgroup analysis of 41-70% total body surface area burned. In that subgroup there were zero cases of death in the treatment group versus five cases in the control group (p=0.005). Our findings suggest that in acute burns, lactobacillus bacteria food additives may be clinically beneficial in patients with total burned body surface area of 41-70%.

[Experimental research on the effects of Chinese herb drugs on immune dysfunction in severely scalded rats].

OBJECTIVE: To observe the modulation effect of a concoction of Chinese herb drugs on immune dysfunction in severely burned rats. METHODS: One hundred healthy Wistar rats were randomly divided into A group (n = 30, with Chinese herb drug feeding after burns), B group (n = 30, with bouillon feeding after burns), C group (n = 30, with ordinary feeding after burns), and D group (n = 10, with sham burns as normal controls). The rats in A, B and C groups were subjected to 30% TBSA full-thickness burns and received conventional treatment. The rats in A group received 2 ml of Chinese herbal drug at 37 degrees C by gavage two times a day beginning from 2 postburn-hours(PBH). The rats in B group received 2 ml bouillon by gavage instead, and otherwise treatment was the same as A group, while the rats in C group were not fed by gavage. The activity of natural killer cell and T lymphocyte, and the levels of IgA, IgG, IgM, C3, C4 in A, B, C groups were examined on 3, 7, 14 PBD, and these indices were also determined in D group. RESULTS: Compared with D group, the amount of the CD3+, CD4+ lymphocyte, the ratio of the CD4+/CD8+, the level of IgA, IgG, IgM, C3, C4, the activity of NK cells, and the density of the sIgA in A, B, C groups were obviously decreased, but the amount of the CD8+ were obviously increased (P < 0.05 or P < 0.01). Furthermore, the above indices in A group improved more quickly when compared with B and C groups. CONCLUSION: The concoction of Chinese herb drugs can improve the distribution of T lymphocyte subsets, increase the activity of NK cells, promote the secretion of sIgA in intestinal mucous membrane and promote recovery of IgM, IgG, C3, C4 levels, thereby improves the immune function of the body.

Effects of early enteral arginine supplementation on resuscitation of severe burn patients.

OBJECTIVES: To investigate the effects of dietary supplementation of l-arginine (l-Arg) on shock in severely burned patients. METHODS: This was a prospective, randomized, single blind, controlled study. Forty-seven severely burned patients due to various causes with a total burn surface area (TBSA) more than 50% each admitted in early postburn phase (within 10h postburn) were included in this study. All patients were treated by the traditional resuscitation program of our institute. After the nasogastric feeding tube was placed, they were randomly divided into three groups-(1) group A400 (n = 16): giving gastrointestinal feeding with 500 ml 5% GNS, containing l-Arg (400 mg/ kgday) at equal pace with fluid resuscitation; (2) group A200 (n = 16): giving gastrointestinal feeding with 500 ml 5% GNS containing l-Arg (200 mg/ kgday); (3) group C (n = 15): giving gastrointestinal feeding with 500 ml 5% GNS without any supplementation. The feeding started within 12h after burn and lasted for 72 h, the feeding rate was controlled by an enteral feeding pump. The following parameters were observed on days (PBD) 1-4: serum nitric oxide content (NO), mean arterial blood pressure (MAP), oxygenation index (PO2/FiO2), and arterial blood content of lactic acid (LA). Gastric mucosal blood flow was measured by laser Doppler flow-metry on PBD1 and PBD2. RESULTS: (1) Enteral feeding of l-Arg did not change MAP of severely burned patients, with no difference in MAP between the l-Arg supplemented and control groups. (2) There were significant changes of the l-Arg supplemented groups (A400 and A200), with an increased gastric mucosa blood flow, oxygenation index, and a decreased LA content in arterial blood, compared with the control group. (3) The serous NO content was significantly decreased in the A400 group on PBD2-4 (P < 0.01), and in the A200 group on PBD4 (P < 0.05) compared with the control group. CONCLUSIONS: Enteral feeding with l-arginine supplementation on early stage of burn decreases NO production to a relatively normal level and exerts beneficial effects on the resuscitation of burned shock.

Controlled study of enteral arginine supplementation in burned children: impact on immunologic and metabolic status.

OBJECTIVE: We compared the effects of an arginine-supplemented diet with those of an isocaloric isonitrogenous diet on immune and metabolic response of children with burns. METHODS: This was a double-blind, randomized, placebo-controlled trial in a burn treatment center of a pediatric hospital in Santiago, Chile. All children (1-5 y of age) admitted within 48 h of a moderate to deep burn injury covering 10% to 40% of total body surface area were evaluated. Twenty-eight children met the criteria and were randomly assigned to receive an arginine-supplemented diet (AG; n = 14) or an isocaloric isonitrogenous diet (CG; control, n = 14) for 14 d. Samples were collected at admission (baseline) and on days 7 and 14 for lymphoproliferative response to mitogens, plasma interleukins (interleukin-1, interleukin-6, tumor necrosis factor-alpha), plasma arginine and ornithine levels, serum C-reactive protein, prealbumin, albumin, glucose, and total urinary nitrogen. RESULTS: The AG enhanced lymphoproliferative responses (analysis of variance, P < 0.05), which were 72% of normal at baseline in both groups; by day 7 responses increased to 144% in the AG group and decreased to 56% in the CG group; both groups returned to normal by day 14. Baseline interleukin-6 was significantly increased in all children. There were no differences in plasma concentrations of interleukin-1, interleukin-6, tumor necrosis factor-alpha, C-reactive protein, prealbumin, albumin, or glucose between the AG and CG groups. On day 7 plasma ornithine levels increased significantly in the AG versus CG group (P < 0.05); arginine levels showed no change. CONCLUSIONS: An exclusively AG improves mitogen-stimulated lymphocyte proliferation in burned children. The benefits of arginine for the immune system do not appear to be related to a metabolic response. The biological significance of this finding remains to be determined.

Treatments for damaged skin.

This is the fifth of a series of articles looking at the available evidence for complementary medicine relating to the theme topic in Australian Family Physician. Any ointment or device when applied to damaged skin whether it be burned or cut, has a legion of tasks to perform: maintaining the integrity of the skin affected, repelling infective agents, and promotion of the healing process.