Route of Feeding

Wherever possible, the enteral route should be used. The American Gastroenterological Association has strongly endorsed this view and stated that routine parenteral nutrition is contraindicated if the enteral route is available. Nasogastric, nasojejunal, and percutaneous enteral access tubes have all been used successfully when feeding is introduced as soon after burn injury as possible. Jejunal feeding is associated with a higher success rate than gastric feeding and may be continued even in the presence of gastric stasis. Increased mortality has been associated with

Table 6 Scheme for nutritional monitoring in a patient with a burn injury

Day 0

Day 2/3

Day 4/5 and twice weekly

Day 6/7 and weekly

Record:

a. Age b. Height c. Urine output d. Oral fluid/food intake

Investigate:

a. Plasma prealbumin b. Electrolytes and urea c. Hemoglobin and hematocrit

Intervention:

a. If burn area >20%, place nasoenteral feeding tube, nasojejunal if possible, start feeding according to calculated values b. Intravenous crystalloid, blood, and colloid according to center protocol Investigate:

a. Indirect calorimetry, energy requirement, calorie balance b. 24-h UUN

c. Urinary myoglobin d. Hematocrit Intervention:

a. Adjust calorie intake to match calculated need b. If intolerant of enteral feeding, reduce to 10-30 ml/h and start TPN to supplement calorie and nitrogen delivery

Investigate:

a. Plasma prealbumin b. Hematocrit c. Indirect calorimetry, as above Intervention:

a. Calculate nitrogen balance; adjust nitrogen intake b. Adjust calorie intake

Investigate:

a. Weight b. Trace elements c. Weekly need for dressing changes and/or surgery d. Is enteral absorption improving? Stop/reduce TPN

e. Is oral intake increasing? Is enteral supplementation still needed?

Intervention:

a. Adjust calorie intake to account for (c) above b. Add trace elements if indicated c. Review route(s) of feeding

Estimate:

c. Need for dressings/ surgery/activity d. Fluid loss the use of central venous catheters and TPN in patients with severe burn injury. This is related to both catheter-associated morbidity and depression of gut function. Glutamine is relatively unstable and has not been included in parenteral formulations. New preparations containing the dipeptide or acetylated form of glutamine will be available in the future that may be of benefit to patients who are dependent on TPN.

Patients with burn injuries greater than 10% are often unable or unwilling to increase their oral intake to meet calorie needs, which are higher by a factor of 1.3 compared to normal. For patients with <20% burns, calorie intake can often be met by supplemental nocturnal feeding through a fine-bore feeding tube. For burns >20%, nasoenteral supplementation is essential. Evidence suggests that the earlier nutrition is started, the greater the attenuation of the hypermetabolic and catabolic response. Early feeding, within 6 h of injury, is optimal. Ent-eral delivery of glucose and glutamine maintains mucosal integrity and reduces gut ischaemia, as shown by a reduction in arterial-to-intraluminal CO2 gap. This latter measure can identify an imbalance between calories presented and oxygen delivered to the gut and may be used to adjust enteral feeding levels to prevent excessive delivery.

Some patients are intolerant of enteral feeding, especially those needing mechanical ventilation, who require high levels of opiate analgesia and exogenous norepinephrine support. In these patients, TPN is needed. Wherever possible, a slow, continuous presentation of enteral feed should also be provided to prevent intestinal mucosal atrophy and preserve immune function. Whichever routes are required, calorie provision should be guided by nutritional monitoring of energy expenditure and nitrogen balance.

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