Clinical Connections April 16, 2014 - University of … Connections April 16, 2014 7 PARAMETERS TO...
Transcript of Clinical Connections April 16, 2014 - University of … Connections April 16, 2014 7 PARAMETERS TO...
Clinical Connections
April 16, 2014
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Stacey Hilliard RD, LDN
Rick Varner RD, CDE, LDN
NUTRITION AND THE BURN PATIENT
• Prevent weight loss
• Preserve lean body mass
• Promote healing
GOALS OF NUTRITION THERAPY
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• ASSESS PATIENT WITHIN 48 HOURS (TRY 24 HRS)
• FOLLOW UP WITH THE PATIENT EVERY 3 DAYS
• WEEKLY MULTIDISCIPLINARY BURN ROUNDS
RESPONSIBILITIES OF THE DIETITIAN
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EBB PHASE NUTRITION
• Ebb Phase
– 2 – 48 hours post injury
– Metabolic shock
– Blood shunted away from major organs
– Decreased energy needs
FLOW PHASE NUTRITION
• Flow Phase – Hemodynamic stabilization
– Metabolic stress • “Fight or Flight” response activated by hormones
– glucagon, cortisol, epinephrine, norepinephrine
– Hypermetabolism & catabolism • glycogenolysis/gluconeogenesis
• free fatty acid mobilization
• protein syntesis, breakdown of skeletal muscle
– Hyperglycemia
– Increased energy and protein needs d/t increases in: • REE, O2 consumption, body temp., cardiac output
RECOVERY PHASE NUTRITION
• Recovery Phase
– Return to anabolism
– Energy/protein needs approach normal
– Eating patterns return to normal
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• HEIGHT
• ADMIT WT
• USUAL WT
• % TBSA
• FOOD ALLERGIES / INTOLERANCES
• DIFFICULTY CHEWING / SWALLOWING
• SUPPLEMENTS PRIOR TO ADMISSION
• PREVIOUS GASTROINTESTINAL ISSUES
• PREVIOUS SUBSTANCE ABUSE?
ESSENTIAL INFORMATION REQUIRED
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CALCULATING ENERGY NEEDS
ASSESSING THE BURN PATIENT
• J.B. is a 30 year old male who sustained ~ 25%
TBSA when he poured gasoline onto a campfire
• + ETOH on admit
• Intubated
• No inhalation injury
• Burns are partial and full thickness
• S/P excision
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CALCULATING ENERGY NEEDS
HARRIS BENEDICT EQUATION:
Female:
655 + (9.6 x kg) + (1.7 x cm) – (4.7 x age)
Male:
66 + (13.7 x kg) + (5x cm) – (6.8 x age)
Stress Factors:
• 1.2-1.4 = <20% TBSA
• 1.6 = 20-25% TBSA
• 1.7 = 25-30% TBSA
• 1.8 = 30-35% TBSA
• 1.9 = 35-40% TBSA
• 2.0 = 40-45% TBSA
• 2.1 = >45% TBSA
FACTS
• J.B. is 6’2” and 198 lbs (104% IBW)
• 25% TBSA
• 30 years old
Estimated EEN using HBE:
• 66 + (13.7 x kg) + (5x cm) – (6.8 x age) =
• 66 + 1233 +939.8 – 204 = 2035 kcal / day
• 2035 x SF (1.6 – 1.7) = 3256 – 3460 kcal / day
PROTEIN NEEDS
• 20-25% total kcal /day
• If the burn is > 20% TBSA use 25% total kcal
In J.B.’s case 20-25% total kcal (3256–3460 kcal)
Protein needs = 173-204g
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April 16, 2014
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FEEDING
• If patient cannot eat (ex: intubated / or
dysphagia) preferred method is enteral
nutrition
• High kcal / High protein formula
• Arginine / Glutamine
• Omega 3 Fatty Acids
TUBE PLACEMENT & ADVANCEMENT
• Post pyloric
• Start at ½ goal rate increase as tolerated
toward goal
• Monitor for residuals greater than 400 ml
J. B.
• In this case based on UPMC Mercy formulary I
would select Pivot 1.5 with goal rate of 90 ml / hr
x 24 hours (3240 kcal, 204g protein and 1639 ml
fluid).
• Once patient fully resuscitated – fluid
recommendations as usual. (ie.:250 ml free H20
q 4 hours.)
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GI ISSUES
• Diarrhea – If on antibiotics
• Ileus – decreased GI motility due to pain
medications
• Gastroparesis – decreased GI motility most
common with poorly controlled diabetes
SUPPLEMENTS
• MVI
• VITAMIN C = 500 mg TWICE DAILY
• ZINC SULFATE = 220 mg ONCE DAILY
• VITAMIN A = 10,000 IU DAILY
ADDITIONAL CONSIDERATIONS:
• Oxandrin – patient must be receiving adequate
protein.
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PARAMETERS TO MONITOR
• Weekly Weight
• Prealbumin • 2 x week if ≥20% TBSA; 1 x week if <20% TBSA
• Electrolytes
• % TBSA
• CRP
• Glucose – goal for control • Critical care – 140-180 mg/dl
• Non Critical care – <140 mg/dl (pre- meal)
– <180mg /dl (random)
INTACT MILD MODERATE SEVERE
16-40 mg/dL 10-15 mg/dL 5-10 mg/dL <5 mg/dL
PREABLUMIN
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ONCE EXTUBATED
• Speech evaluation for safe swallowing
• Advance diet
• Cycling of tube feeding
• Addition of oral supplements
• Education on high protein / high calorie
foods
• Education on status of prealbumin
• Food preferences / tolerances
• Calorie counts
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J.B.’s NORMAL DAILY PROTEIN
J.B.’s BURN DAILY PROTEIN
HIGH CALORIE / HIGH PROTEIN MEAL
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FOODS / SUPPLEMENTS
ITEM PROTEIN KCALS
3 oz meat 21g 165-300
2 EGGS 14g 150
½ Cup Cottage Cheese 14g 120-150
1TBSP Peanut butter 7g 100
2 Strips Bacon 7g 100
1 oz Cheese 7g 75-100
Milk (8oz) 8g 80-150
Yogurt(6oz) 5g 100-170
Greek Yogurt(6oz) 11-16g 150
Boost VHC 22g 530
Ensure Complete 13g 350
Ensure Immune Health 9g 250
LiquaCel 16g 90
INCREASING PROTEIN INTAKE
• Double protein portions all meals
• Peanut butter
• Milk x 2 all meals
• Oral supplements
• Yogurt all meals
• Puddings
• Cottage cheese
• Protein modules
• HS snack
ROAD BLOCKS
• Nausea / vomiting
• Diarrhea / constipation
• Depression
• Unable to use fingers or hands,
burned lips, sore mouth or throat.
• Missing meals for hydrotherapy (meal timing / do
not hold tube feeding)
• No appetite / not normally a big eater
• Pain
• Bored with food choices / LOS
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PARAMETERS TO MONITOR
• Weight weekly
• Any change in %TBSA
– Recalculated weekly or after surgery
– Can be readjusted
• Prealbumin
• Oral intake / calorie counts
• Any GI issues
PEDIATRIC PATIENT
Mayes Formula
• Patients younger than 3 years of age
Mayes 1 = 108 + 68W + 3.9 x %burn
Mayes 2 = 179 + 66W + 3.2 x %third-degree burn
• Patients >3 to 10 years of age
Mayes 3 = 818 + 37.4W + 9.3 x %burn
Mayes 4 = 950 + 38.5W + 5.9 x %third-degree burn
CALCULATING ENERGY NEEDS
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CALCULATING ENERGY NEEDS
Category Age (y) Maintenance/kg +% burn kcal/d
Infants 0-1 98-108 +15 x %TBSA
Children 1-3 102 +25 x %TBSA
4-6 90 +40 x %TBSA
7-10 70 +40 x %TBSA
Male 11-14 55 +40 x %TBSA
15-18 45 +40 x %TBSA
Female 11-14 47 +40 x %TBSA
15-18 40 +40 x %TBSA
DIET
• Age appropriate diet
– Obtain food preferences from family if available
– Educate family on high protein / high kcal foods
Poor intake / or larger burns
• Calorie counts
• Appetite Stimulant
• ex: Periactin often used in pediatrics
• post-pyloric tube feeding can be used
ex: PediaSure 1.5 (specialized for pediatric pts.)
or
1.0 kcal/ml, low-fat formula is recommended for
pediatric burn pts. w/ increased needs
PREALBUMIN
Age Male (mg/dl) Female (mg/dl)
1-40 days 3.2 – 15.9 4.2 – 14.4
41-90 days 2.7 – 17.6 2.5 – 21.9
3-9 months 7.3 – 27.9 5.3 – 25.0
10-24 months 6.7 – 28.5 7.3 – 33.7
2-10 years 6.9 – 31.2 8.0 – 35.2
11-15 years 6.3 – 33.5 8.6 – 40.7
16-18 years 8.0 – 41.6 13.7 – 44.1 Pediatric Reference Ranges, Stephen J Soldin ed, AACC Press, 4th Edition
2003, p. 154
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PEDIATRIC SUPPLEMENTS
• Children’s MVI daily (Polyvisol 1 ml/day)
• Vitamin C • Children 1-2 years (< 40 lbs) = 100mg twice daily
• Children 2-3 years ( <40 lbs) = 250mg twice daily
• Children > 3 years (<40lbs) = 500mg twice daily
• Zinc Sulfate • Children 1-2 years (<40 lbs) = elemental zinc 100mcg / kg / day
• Children > 2 years (<40 lbs) = elemental zinc 5mg / day
• Children 2-12 years (>40 lbs) = elemental zinc 10mg / day
• Children > 12 years = 220mg / day
OBSTACLES WITH PEDIATRICS
• Must obtain food preferences from family
• Family dynamics
• Patients are not able to communicate needs
References
• Chan MM, Chan GM. Nutrition Therapy for burns in children and adults. Nutrition 2009;25: 261-269.
• Graves C, Saffle J, Cochran A. Actual Burn Nutrition Care Practices: An Update. J Burn Care & Research. 2009;30(1): 77-81.
• Gottschlich MM, Fuhrman PM, Hammond KA, Holcombe BJ, Seidner DL, Chapter 19: Burn and Wounds Healing. The Science and Practice of Nutrition Support, A cased –Based Core Curriculum. American Society for Parenteral and Enteral Nutrition. Kendall / Hunt 2001, 412-415.
• DeLegge MH, Mattox T, Muller C, Worthington P. Trauma, Surgery, and Burns. The ASPEN Nutrition Support Core Curriculum: A Case-Based Approach-The Adult Patient. 2007; 467-468.
• Nelms M, Sucher K, Long S. Metabolic Stress. Nutrition Therapy and Pathophysiology. Belmont, CA: Wadsworth: 2007. p.786-801.
• Nelms M, Sucher K, Lacey K, Long Roth S. Metabolic Stress. Nutrition Therapy and Pathophysiology, 2nd ed. Belmont, CA: Wadsworth: 2011. p.684-698.
• Mayes T et al. Evaluation of predicted and measured energy requirements in burned children. J Am Diet Assoc, 1996;96(1):24-29.
• Takecomo C, Pediatric Dosage Handbook 17th edition, Lexicom Publishing (2010-2011).
• Custer J, Rau RE, Harriet Lane Handbook 18th edition, John Hopkins Hospital 2008.
• Micromedix 2011