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consumed to generate energy. IDC is often used to determine adequacy of nutrition support in critically ill patients, and has been posited as a necessary means of monitoring in complex patients [89]. Twothirds of responding burn units in a recent survey indicated that they used IDC to monitor energy demands in adult patients [23]. IDC has been used as the “gold standard” for comparison of other methods of calculating energy demands in both adult and pediatric burn populations [26, 90]. Equipment for bedside performance of IDC has become more accessible over the last decade, and the associated technology has improved ease of use. However, IDC can be affected by a variety of factors including metabolic acid-base derangements, core temperature abnormalities, need for high levels of oxygen support, and even hyperor hypoventilation. As any of these are commonly present in burn patients, particularly pediatric burn patients, the use of IDC as the sole monitor of nutritional adequacy has been called into question [91, 92]. In the absence of superior monitoring methods, weekly IDC used in conjunction with other means of monitoring nutritional status trends remains a cornerstone of nutrition management in burn patients [5, 90].

Fluctuations in weight can be helpful in healthy patients as they are associated with changes in lean body mass and fat accretion or loss. The fluid shifts resulting from the profound inflammatory response to burn injury as well as the massive fluid volumes required for resuscitation from burn shock confound the use of weight as a surrogate for lean body mass. Because of the complexities of the water component of total body weight, weights are best used in the context of long-term trends and with other nutritional markers [5]. As most fluid shifts have abated by the rehabilitative phase from burn injury, this stage of recovery may be when use of weights is most helpful and least complex.

Application: Monitoring of nutritional therapy in burn patients is complex and should be done using multiple methods and focusing on trends. This patient underwent weekly IDC determinations, as well as measurements of UUN and calculation of nitrogen balance. Alterations in feeding rates only occurred once weekly based upon the constellation of information available from IDC readings and UUN analyses.

Problems and complications of nutritional support

Neither EN nor PN should be considered troublefree. Both have significant complications that can range from mildly troublesome to life-threatening. Awareness and monitoring should detect most problems early, and help avert the worst consequences of nutritional support.

Important complications include:

Under/overfeeding: Almost any disorder of electrolytes, fluids, or homeostasis can accompany prolonged nutritional support. Underfeeding is common in the early phases of burn treatment, when metabolic needs are highest and problems with administration of nutrition greatest. With increased emphasis on the importance of adequate nutrition and improved methods of delivering prolonged support, overfeeding is now more commonly encountered. As indicated previously, the additional caloric loads of IV fluids and some medications can contribute significantly to this problem. In addition to the obvious issue of weight gain and obesity, significant overfeeding of specific nutrients can produce three complications. First, excessive carbohydrate intake results in fat synthesis, elaboration of carbon dioxide, and increased respiratory quotient. In patients with ongoing respiratory failure, this can complicate weaning from respiratory support. This is a particular problem with PN [93]; switching patients to enteral nutrition may help resolve this issue. Use of low-carbohydrate diets may also help but such diets are typically high in fat, which may be harmful to burn patients in other ways. Regular monitoring of respiratory quotient (RQ) by IDC and adherence to calculated calorie guidelines based upon ideal body weight are also helpful.

Excess feeding of carbohydrates or fat to burn patients can also lead to deposition of fat in the liver parenchyma [94]. Hepatic enzyme elevation is common in burn patients regardless of nutrition, and this may be more pronounced with PN and with fluid overload. Hepatic enzymes should be followed regularly in all patients with major burn injuries. Finally, high-protein PN can contribute to azotemia, particularly when dehydration occurs [95]. Serum urea ni-

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trogen and creatinine should be monitored frequently.

Hyperglycemia: Hyperglycemia occurs in up to 90% of all ICU patients during critical illness [96]. Burn patients are particularly prone to this problem, given their preponderance of catabolic hormones which cause relative insulin resistance – the “diabetes of injury”. Both acute and chronic hyperglycemia is associated with immune deficiency and increased susceptibility to infection. Infection, in turn, exaggerates glucose intolerance, so the two problems often perpetuate each other.

Recent increased awareness of the value of glycemic control has led to several studies that attempted to maintain strict glucose control. In a widely-cited study, surgical ICU patients randomized to a regimen of “intensive” glucose control (maintaining levels at 80 –110 mg/dL) had substantial reductions in mortality, organ failure, and other parameters, compared to patients given “traditional” treatment aimed at maintaining glucose at 180–200 mg/dL [97]. Additional evidence suggests that insulin may itself be beneficial by reducing circulating levels of C-reactive protein and other inflammatory mediators [98, 99]. These findings helped stimulate widespread recommendations for very rigorous glucose control in ICU populations [100]. However, use of these protocols has been called into question by other recent large studies suggesting that intensive insulin therapy is associated with increased mortality and a much higher incidence of critical hypoglycemia with attendant neuropsychiatric complications [101]. Although the value of blood sugar control is undisputed, the exact target level for blood sugar remains poorly defined; methodological differences and the ability of different ICU’s to provide safe and effective glucose control appear to affect these results significantly [102]. Current recommendations are for “moderately strict” glucose control (target levels of 110 –150 mg/ dL), which would appear to offer many of the benefits of intensive therapy while minimizing the associated risks [3].

It is clear that hyperglycemia is both more severe and more common with PN as opposed to enteral nutrition, as are the extreme complications of catastrophic hypoglycemia and hyperosmolar coma. The nursing time and effort required for any aggressive

regimen of blood sugar control is substantial, and this alone constitutes a strong argument for avoiding parenteral nutrition. Even with EN, blood sugar control can be a difficult task in the burn patient and complicates the care of most seriously burned individuals. Avoiding overfeeding is clearly beneficial in this regard and can help make glucose control more readily achievable. Use of oral hypoglycemic agents such as metformin and some anabolic hormones also help in blood sugar management [103].

Bowel necrosis: In recent years, reports have documented bowel necrosis and perforation in critically-ill patients given aggressive enteral nutrition [104, 105]. This problem may be increasing in frequency in burn patients [106]. A number of possible explanations for this phenomenon have been proposed, including occult abdominal compartment syndrome, use of vasopressors, bacterial overgrowth and stagnation of tube feedings, and bowel distension and ischemia caused by continued infusions in the face of narcotic-induced ileus. Regardless of the cause, mortality for this catastrophic complication is exceedingly high. This is one reason why enteral nutrition is not carefree and that patients must always be watched closely for subtle evidence of distension or distress. Tube feeding intolerance may be a harbinger of impending infection and feedings must sometimes be held in this situation.

Diarrhea: Tube feedings are also frequently associated with diarrhea, which can range from minor to a major source of morbidity, electrolyte losses, and even intestinal necrosis. Often the cause is multifactorial [107], including the osmotic effect of high glucose loads of tube feedings, enteral medications such as antacids and antibiotics, and infectious causes, including pseudomembraneous colitis caused by C. difficile [108]. Overfeeding can play a role here as well by overwhelming the gut’s ability to absorb nutrients. A variety of compounds are used to control diarrhea, including opiates, bulk agents, and fiber-containing formulas [3]. None are entirely successful, and any of these agents can prolong intestinal transit and potentiate intestinal stasis and necrosis [109]. Often a short-term reduction or cessation of feedings will bring diarrhea under control. Diarrhea which persists in spite of optimal medical management should prompt a search for an infectious source inside or outside the bowel [110].

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Comprehensive nutritional regimen: Providing adequate and safe nutritional support to a seriously burned patient can be a significant challenge to the burn team. The most successful approach to doing so is to develop a comprehensive, multidisciplinary regimen, involving physicians, nurses, dieticians, and pharmacists. Assessment of nutritional needs, the success of ongoing efforts to optimize nutrition, and careful monitoring for complications should be a routine part of the daily care of burn patients.

Application: The patient presented above was begun on a nutritional regimen developed by the interdisciplinary burn care team. Placement of the enteral feeding tube was ordered on admission as part of a standard order set. During multi-disciplin- ary rounds the next day, the dietician recommended the formula to be used and the target rate, and physicians ordered a standard protocol for increasing the infusion. The regimen was adjusted to include consideration of other sources of caloric intake, and the need to provide a high-protein formula, as discussed previously. Routine monitoring, also ordered at this time, included daily electrolytes and twice-weekly hepatic enzymes, indirect calorimetry (IDC), nitrogen balance determinations, and body weights. Blood glucose was monitored according to a protocol, beginning with determinations every 4 hours by nursing staff. When blood sugars remained high on a “sliding scale” regimen of subcutaneous insulin, he was switched to an intensive regimen of continuous insulin infusion and hourly blood sugar determinations. Nutritional status was reviewed on daily rounds with the entire team.

On hospital day 12, indirect calorimetry indicated that the patient’s caloric expenditure had increased to 3,100 kcal/day and UUN was 22 gm in 24 hours. Because the patient was also receiving approximately 480 kcal/day in the form of dextrose-containing IV fluids (100 mL/hr) and 240 kcal/day from propofol for sedation (9 mL/hr), tube feedings were increased to a rate of 100 mL/hr for a total intake of 3,120 kcal and 148 gm protein per day (24 gm of nitrogen). Blood sugar control was better, so the continuous insulin infusion was stopped and the sliding scale restarted. Twelve days later, following three successful surgeries, IDC had dropped to 2,300 kcal/day; nitrogen balance was positive by 9 gm/day, and mild azotemia

(BUN 30 mg/dL, creatinine 1.6 gm/dL) was present despite good hydration. At this time propofol had been discontinued, and total IV fluid volume remained at 100 mL/hr (480 glucose kcal/day). Therefore, the enteral formula was changed to Osmolite providing 106 kcal and 4.4 gm protein/100 mL, and the rate was reduced to 72 mL/hr (1,831 kcal, 76 gm protein, 12.1 gm nitrogen per day).

On hospital day 21 the patient began to take oral fluids. He was started on high-calorie milkshakes, and tube feedings were held during waking hours to improve his appetite. Within 5 days he was able to take a normal diet, and the feeding tube was removed.

Conclusion

Providing optimal nutritional support to the burn patient presents a number of unique challenges. Many of these can be solved with appropriate attention to specific nutritional requirements, careful monitoring, and a multi-disciplinary approach to nutrition that is integrated into the total program of burn care. Additional research into almost every aspect of burn-spe- cific nutrition will be needed to resolve the controversies which still surround this important but imperfectly-understood aspect of burn care.

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Correspondence: Amalia Cochran M.D., FACS, Dept. of Surgery, 3B-313, University of Utah Health Center, 50 N. Medical Dr., Salt Lake City, UT 84132, Tel: [phone], Facsimile: 801 587 9147, E-mail: [e-mail]

Jeffrey R. Saffle M.D., FACS, Dept of Surgery, 3B-306, University of Utah Health Center, 50 N. Medical Dr., Salt Lake City, UT 84132, Tel: [phone], Facsimile: 801 585 2435, E-mail: [e-mail]

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