Recomendaciones para el tratamiento nutrometabólico especializado del paciente crítico: paciente politraumatizado y paciente quemado crítico. Grupo de Trabajo de Metabolismo y Nutrición de la Sociedad Española de Medicina Intensiva, Crítica y Unidades Coronarias (SEMICYUC) / Recommendations for specialized nutritional-metabolic management of the critical patient: Special situations, polytraumatisms and critical burn patients. Metabolism and Nutrition Working Group of the Spanish Society of Intensive and Critical Care Medicine and Coronary Units (SEMICYUC)

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Geometric framework reveals that a moderate protein, high carbohydrate intake is optimal for severe burn injury in mice.

Nutritional therapy is a cornerstone of burns management. The optimal macronutrient intake for wound healing after burn injury has not been identified, although high-energy, high-protein diets are favoured. The present study aimed to identify the optimal macronutrient intake for burn wound healing. The geometric framework (GF) was used to analyse wound healing after a 10 % total body surface area contact burn in mice ad libitum fed one of the eleven high-energy diets, varying in macronutrient composition with protein (P5-60 %), carbohydrate (C20-75 %) and fat (F20-75 %). In the GF study, the optimal ratio for wound healing was identified as a moderate-protein, high-carbohydrate diet with a protein:carbohydrate:fat (P:C:F) ratio of 1:4:2. High carbohydrate intake was associated with lower mortality, improved body weight and a beneficial pattern of body fat reserves. Protein intake was essential to prevent weight loss and mortality, but a protein intake target of about 7 kJ/d (about 15 % of energy intake) was identified, above which no further benefit was gained. High protein intake was associated with delayed wound healing and increased liver and spleen weight. As the GF study demonstrated that an initial very high protein intake prevented mortality, a very high-protein, moderate-carbohydrate diet (P40:C42:F18) was specifically designed. The dynamic diet study was also designed to combine and validate the benefits of an initial very high protein intake for mortality, and subsequent moderate protein, high carbohydrate intake for optimal wound healing. The dynamic feeding experiment showed switching from an initial very high-protein diet to the optimal moderate-protein, high-carbohydrate diet accelerated wound healing whilst preventing mortality and liver enlargement.

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.

Nutrition: reducing the hypermetabolic response to thermal injury.

Nutritional support is seen as a vital component in the battle to attenuate the extreme hypermetabolic response experienced by patients suffering from large thermal injuries. Protein catabolism precipitating protein malnutrition places patients at greater risk of wound infection and sepsis due to delayed wound healing. Underfeeding, aggressive feeding, feeding routes, timing of initiation of feeding and tight insulin control have all been explored extensively in the quest to understand what nutritional treatment will best attenuate the hypermetabolic response. Despite this it is suggested that the majority of patients with large thermal injuries do not receive adequate nutritional support immediately post injury. Nurses have a pivotal role to play in ensuring that thermal injury patients receive appropriate nutritional support based on the best available evidence.

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.

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.

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

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Impact of decreasing energy intakes in major burn patients: A 15-year retrospective cohort study.

BACKGROUND & AIMS: Nutritional therapy is particularly important after major burn injury and specific nutritional guidelines have been developed. The study aimed at evaluating the impact of the changes in our nutritional practice, general compliance with the guidelines and potential consequences. METHODS: Retrospective analysis of prospectively collected data in burn patients requiring intensive care (ICU) between 1999 and 2014. INCLUSION CRITERIA: admission on day 1, full treatment and length of ICU stay >7 days. Four periods (P) were defined by protocol changes (P1: 1999-2001, P2: 2002-2005, P3: 2006-2010, P4: 2011-2014). Collected data: demographic and nutritional data, infectious complications, weights, CRP and prealbumin concentrations during the first 21 days. RESULTS: 240 patients were included (median age 43 years, burned area 25%). Measured energy expenditure (MEE) was stable through all periods but the prescribed caloric target decreased significantly, and below MEE (P1: 33 kcal/kg, IQR 7, P4: 28 kcal/kg, IQR 8, p < 0.001). Energy delivery ended decreasing below 30 kcal/kg/day (P1: 30 kcal/kg, IQR 23, P4: 25 kcal/kg, IQR 12, p < 0.001). Protein intakes increased due the use of high protein solutions and glutamine (P1: 1.04 g/kg, IQR 0.90, P4: 1.26, IQR 0.99, p < 0.001). Weight loss by day 21 increased significantly according to area under the curve (P1: 701, IQR 38, P2: 722, IQR 51, P4: 689 IQR 63, p = 0.02). Prealbumin levels decreased with energy decrease (P1: 150 mg/L, IQR 110, P4: 80 mg/L, IQR 70, p = 0.003). CONCLUSIONS: The observed reduction of the energy delivery <30 kcal/kg was associated with a supplemental weight loss and lower prealbumin concentrations.

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.

High-carbohydrate, high-protein, low-fat versus low-carbohydrate, high-protein, high-fat enteral feeds for burns.

BACKGROUND: Severe burn injuries increase patients' metabolic needs. Aggressive high-protein enteral feeding is used in the post-burn period to improve recovery and healing. OBJECTIVES: To examine the evidence for improved clinical outcomes in burn patients treated with high-carbohydrate, high-protein, low-fat enteral feeds (high-carbohydrate enteral feeds) compared with those treated with low-carbohydrate, high-protein, high-fat enteral enteral feeds (high-fat enteral feeds). SEARCH METHODS: We searched the Cochrane Injuries Group Specialised Register (searched 28 Nov 2011), Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 4), MEDLINE (Ovid) 1950 to Nov (Week 3) 2011, EMBASE (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to Nov 2011), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (1990 to Nov 2011), PubMed (Searched 28 Nov 2011). Online trials registers and conference proceedings were also searched to April 2010. SELECTION CRITERIA: We included all randomized controlled trials (RCTs) comparing high-carbohydrate enteral feeds to high-fat enteral feeds for treatment of patients with 10% or greater total body surface area (TBSA) burns in the immediate post-burn period, with data for at least one of the pre-specified outcomes. DATA COLLECTION AND ANALYSIS: Two authors collected and analysed the following data: mortality, incidence of pneumonia and days on ventilator. Meta-analysis could only be performed for the outcomes mortality and incidence of pneumonia. A random-effects model was used for all comparisons. MAIN RESULTS: Two RCTs, reporting results from 93 patients, were included in this review. Patients given a high-carbohydrate feeding formula had an odds ratio (OR) of 0.12 (95% confidence interval (CI) 0.04 to 0.39) for developing pneumonia compared to patients given a high-fat enteral formula (P value = 0.0004). Patients given a high-carbohydrate formula had an OR of 0.36 (95% CI 0.11 to 1.15) for risk of death compared to patients given a high-fat enteral formula; this difference did not reach statistical significance (P value = 0.08). Risk of bias in these studies was assessed as high and moderate. AUTHORS' CONCLUSIONS: The available evidence suggests that use of high-carbohydrate, high-protein, low-fat enteral feeds in patients with at least 10% TBSA burns might reduce the incidence of pneumonia compared with use of a low-carbohydrate, high-protein, high-fat diet. The available evidence is inconclusive regarding the effect of either enteral feeding regimen on mortality. Note that the available evidence is limited to two small studies judged to be of moderate risk of bias. Further research is needed in this area before strong conclusions can be drawn.

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)

Burns, metabolism and nutritional requirements / Quemaduras, el metabolismo y los requerimientos nutricionales

Objectives: To review the nutritional evaluation in burned patient, considering the literature descriptions of nutritional evaluation and energy requirements of these patients. Introduction: Thermal injury is the traumatic event with the highest metabolic response in critically ill patients. Various mathematical formulas have been developed to estimate nutritional requirements in burned patient. Indirect Calorimetry is the only method considered gold standard for measuring caloric expenditure. Methods: A survey of the literature and data was collected based on official data bases, LILACS, EMBASE and PubMed. Results: The metabolic changes involved in hypermetabolism are designed to supply energy to support immune function, brain activity, wound healing, and preservation of body tissues. Body weight is considered the easiest indicator and perhaps the best to assess the nutritional status. The most common formulas utilized in these patients are the Curreri, Pennisi, Schofield, Ireton-Jones, Harris-Benedict and the ASPEN recommendations. For children is the Mayes and World Health Organization formula. The majority of mathematical formulas overestimate the nutritional needs. The regular use of Indirect Calorimetry supplies adequate nutritional support to the burn patient. Discussion: The traditional nutritional evaluation considers anthropometry, biochemical markers and estimation of nutritional requirements. The weight provides abasis for decisions that are established in the clinical context. Classic parameters can be adapted to intensive care environment. Conclusions: The use of Indirect Calorimetry is crucial to ensure the safety of the nutritional support of burn patients and this should be widely encouraged (AU)

Objetivos: Revisar la evaluación nutricional del paciente quemado, considerando las descripciones bibliográficas de la evaluación nutricional y de los requerimientos energéticos de estos pacientes. Introducción: la lesión térmica es el acontecimiento traumático con la mayor respuesta metabólica en los pacientes críticos. Se han desarrollado diversas fórmulas matemáticas para estimar los requerimientos nutricionales del paciente quemado. La calorimetría indirecta es el único método de referencia para medir el gasto calórico. Métodos: se realizó una revisión bibliográfica y una recogida de datos a partir de las bases de datos oficiales LILACS, EMBASE y PubMed. Resultados: Los cambios metabólicos que implican un hipermetabolismo están diseñados para aportar energía para mantener la función inmunitaria, la actividad cerebral y la curación de las heridas así como la conservación de los tejidos corporales. Se considera que el peso corporal es el indicador más sencillo y quizás el óptimo para evaluar el estado nutritivo. Las fórmulas más frecuentemente empleadas en estos pacientes son Curreri, Pennisi,Schofield, Ireton-Jones, Harris-Benedict y las recomendaciones de ASPEN. En los niños son la de Mayes y la de la Organización Mundial de la Salud. La mayoría de las fórmulas matemáticas sobre estiman las necesidades nutricionales. El uso habitual de la calorimetría indirecta proporciona un soporte nutricional adecuado en el paciente quemado. Discusión: La evaluación nutricional tradicional considera la antropometría, los marcadores bioquímicos y la estimación de los requerimientos nutricionales. El peso proporciona la base para las decisiones que se establecen en el contexto clínico. Los parámetros clásicos pueden adaptarse al ambiente de los cuidados intensivos. Conclusiones: el uso de la calorimetría indirecta es crucial para asegurar la seguridad del soporte nutricional de los pacientes quemados por lo que debería potenciarse (AU)

The results of a national survey regarding nutritional care of obese burn patients.

Little is known about the nutritional needs of obese burn patients. Given the impact of obesity on the morbidity and mortality of these patients, a uniform understanding of perceptions and practices is needed. To elucidate current practices of clinicians working with the obese burn population, the authors constructed a multidisciplinary survey designed to collect this information from practitioners in United States burn centers. An electronic approach was implemented to allow for ease of distribution and completion. A portable document format (pdf) letter was e-mailed to the members of the American Burn Association and then mailed separately to additional registered dietitians identified as working in burn centers. This letter contained a link to a 29-question survey on the SurveyMonkey.com server. Questions took the form of multiple choice and free text entry. Responses were received from physicians, mid-level practitioners, registered dietitians, and nurses. Seventy-five percent of respondents defined obesity as body mass index >30. The Harris-Benedict equation was identified as the most frequently used equation to calculate the caloric needs of burn patients (32%). Fifty-eight percent indicated that they alter their calculations for the obese patient by using adjusted body weight. Calculations for estimated protein needs varied among centers. The majority did not use hypocaloric formulas for obese patients (79%). Enteral nutrition was initiated within the first 24 hours for both obese and nonobese patients at most centers. Sixty-three percent suspend enteral nutrition during operative procedures for all patients. Oral feeding of obese patients was the most preferred route, with total parenteral nutrition being the least preferred. Longer length of stay, poor wound healing, poor graft take, and prolonged intubation were outcomes perceived to occur more in the obese burn population. In the absence of supporting research, clinicians are making adjustments to the nutritional care of obese burn patients. This indicates the need for further research to determine consistent best practices.

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.

Perfil epidemiológico e antropométrico de pacientesinternados em uma unidade de tratamento de queimadosem Brasília, Distrito Federal / Epidemiologic and anthropometric profile of patients hospitalizedin a burn treatment unit in Brasília, Distrito Federal

A queimadura é um tipo de trauma caracterizado por alteraçõesmetabólicas e imunológicas sistêmicas. O paciente queimado é altamente suscetível à desnutrição, devido a fatores como perda ponderal intensa e o balanço nitrogenado negativo.

The burn injury is a kind of trauma characterized by metabolic and immunological alterations. The burned patient is highly susceptible to malnutrition due to factors such as severe weight loss and negative nitrogen balance.

Association between dietary fat content and outcomes in pediatric burn patients.

BACKGROUND: The aim of the study was to compare a low fat/high-carbohydrate diet and a high-fat diet on clinical outcomes by a retrospective cohort study. METHODS: Nine hundred forty-four children with burns ≥ 40% of their total body surface area (TBSA) were divided into two groups: patients receiving Vivonex T.E.N. (low-fat/high-carbohydrate diet; n = 518) and patients receiving milk (high-fat diet; n = 426). Patient demographics, caloric intake, length of hospital stay, and incidence of sepsis, mortality, hepatic steatosis, and organomegaly at autopsy were determined. RESULTS: Demographics and caloric intake were similar in both groups. Patients receiving Vivonex T.E.N. had shorter (intensive care unit) ICU stays (Vivonex T.E.N.: 31 ± 2 d; milk: 47 ± 2 d; P < 0.01), shorter ICU stay per % TBSA burn (Vivonex T.E.N.: 0.51 ± 0.02 d/%; milk: 0.77 ± 0.03 d/%; P < 0.01), lower incidence of sepsis (Vivonex T.E.N.: 11%; milk: 20%; P < 0.01), and lived significantly longer until death than those receiving milk (Vivonex T.E.N.: 20 ± 3 d; milk: 10 ± 2 d; P < 0.01). There was no difference in overall mortality between the two groups (Vivonex T.E.N.:15% versus milk: 13%; P < 0.9). Autopsies revealed decreased hepatic steatosis and decreased enlargement of kidney and spleen in patients receiving Vivonex T.E.N. CONCLUSIONS: The period with a low-fat/high-carbohydrate diet was associated with lower LOS, decreased incidence of organomegaly, infection, and hepatic steatosis post-burn compared with the period when a high-fat diet was used. These associations indicate the benefit of high carbohydrate/low fat nutrition; however, the findings in these time periods can also be likely due to the multifactorial effects of advances in burn care. We believe that these results have some relevance because high fat is associated with poorer outcomes compared with low fat.