Burn Unit Nutritional Support

Original Date: 11/2020
Purpose: To ensure burn patients receive optimal support to meet their nutritional requirements for healing and recovery.

*All patients admitted to the burn service will have a Nutrition Consult ordered in Care 4 to assist in ordering nutritional support and screening for pre-existing nutritional deficiencies*

Step One: Oral Intake, Supplements, and Nutrition-Related Medications

  • Oral diet
    • Patients able to consume PO will have a regular diet, unless contraindicated.
    • Patient’s visitors may follow unit policy to bring home-cooked or restaurant foods to serve immediately or store on the unit.
    • Encourage high calorie and high protein foods. Dietitian or Food and Nutrition Service Patient Advocate are available to advise patients on specific foods or menu items.
    • Snacks: high protein, high calorie nourishments will be ordered at the discretion of the dietitian.
  • Supplements
    • Oral nutrition supplements (high protein, high calorie) will be ordered at the discretion of the provider or the dietitian to meet nutritional needs.
      • Ensure Enlive or Boost Glucose/Premier Protein (if diabetic)
  • Nutrition-related medications
    • Multivitamin with minerals
      • Order for all patients with >15% TBSA burn.
      • Those patients will be evaluated by the dietitian and provider to determine if supplementation with additional vitamins and minerals are needed.
    • Oxandrolone
      • Patients with >20% TBSA will be started on oxandrolone 10mg PO q12 hours for hypermetabolic response and preservation of lean body mass
      • LFTs will be checked every Monday
        • Discontinue oxandrolone if LFTS are ever elevated 3x the normal range
      • PSA will be checked prior to initiation in males
        • If PSA >4ng/mL, do not start oxandrolone
      • Patients must be receiving a diet or goal enteral nutrition before initiation

*Encouraging and recording oral intake is the responsibility of all burn staff*

Step Two: Determine if Enteral Nutrition is needed and order appropriate nutritional support

  • Enteral nutrition should be initiated for the following patients:
    • >20% TBSA burn
    • All intubated patients
    • Any patient who cannot meet their nutritional needs with PO intake. Check with Burn ICU attending and Dietitian prior.
    • Patients who arrive with pre-existing malnutrition
  • Feeding access
    • Place nasogastric tube of small bowel feeding tube.
      • Nasogastric tubes are larger and less comfortable but can be suctioned easily.
      • Small bowel feeding tubes are smaller and more comfortable but can clog more easily and cannot be suctioned easily.
    • Order KUB to ensure correct position of the feeding tube.
    • Feeding tubes need to be cleared by KUB prior to feeding and can be used in stomach or post-pyloric. They must be read by a 2nd year resident or higher
  • Tube feeding
    • Enteral nutrition or diet will be initiated within 4-6 hours of admission and advanced to goal rate within 48 hours.
    • Start PhosNak 2 packets q8 hours for all patients on EN due to hypermetabolism (unless potassium or phosphorous levels are elevated).
    • Selecting a formula:
      Patient Condition Formula Calories per mL
      Burn size:
      <30% TBSA
      ≥30% TBSA      		 Peptamen AF®
      Impact Peptide 1.5      		 1.2 kcal/mL
      1.5 kcal/mL
      iHD or hyperkalemia Novasource® Renal 2 kcal/mL
      CRRT Peptamen AF® 1.2 kcal/mL
      Hyperglycemia Peptamen AF® 1.2 kcal/mL
      Diarrhea Replete® Fiber 1 kcal/mL
    • Calculating goal rate:
      • Determine kcal per day needed based upon weight (kg) and TBSA
        • If BMI is >30, use ideal body weight
          Burn Size Daily caloric needs
          0-19% TBSA or inhalational injury 30 kcal/kg
          20-34% TBSA 35 kcal/kg
          ≥35% TBSA 40 kcal/kg
      • Calculate rate
        (1) Total caloric need per day: multiply daily caloric need (kcal/kg) by weight (kg)
        (2) Total amount of enteral formula per day: divide total caloric need per day (1) by the calories per mL of the tube feed formula
        (3) Divide the total amount of enteral formula per day (2) by 22 hours to get the goal rate of x mL per hour
    • Start tube feeds at 20 mL/hour and increase by 20 mL/hour every 4 hours to goal rate. Once tolerating enteral nutrition at goal rate, switch to volume-based feeding protocol.
    • Volume-based feeding
      • Utilized by dietitian to minimize missed feeding time due to operating room, dressing changes, and therapy
      • Once patient is tolerating goal enteral nutrition, switch over to volume-based feedings.
      • Take goal rate and multiply by 22 to get Daily Volume Goal for the entire day.
      • RN adjusts feeding rate at shift change OR when the patient returns from OR if they missed >2hrs of enteral nutrition.
      • RN finds volume infused since 6am via the tube feed pump and subtracts that volume from the Daily Volume Goal to get the Volume Left to Be Fed.
      • RN then calculates the number of hours remaining until 6am the following day and uses the chart on the patient’s door to determine new rate based on Volume Left to Be Fed in the remaining hours until 6am.
      • Maximum volume-based rate is 150mL/hour
    • Gastric residual volume (GRV) and enteral feeding tolerance
      • If GRV <500mL and:
        • No signs of intolerance*, return 300mL aspirate to patient and continue enteral feeding, recheck GRV in 4 hours
        • Signs of intolerance* are present, notify MD.
      • If GRV ≥500mL and:
        • No signs of intolerance*, notify MD, return 300mL aspirate to patient, begin metoclopramide 10mg IV q 6 hours (if metoclopramide already started, add erythromycin IV 250mg q6H), check GRV in 4 hours after metoclopramide dose.
        • Signs of intolerance* are present, notify MD.
      • If GRV remains ≥500mL after 4 doses of metoclopramide and/or signs of intolerance are present:
        • Hold gastric feedings, notify MD, place Small Bowel Feeding Tube, obtain KUB for placement verification, once confirmed initiate EN at 20mL/hr and advance by 20mL/hr q 4hrs to goal rate

*Signs of intolerance: abdominal distention/pain, nausea, emesis, diarrhea, constipation >3 days, a large gastric bubble from x-ray, etc.

Parenteral Nutrition:

  • Parenteral nutrition will be instituted on patients where enteral nutrition is not feasible or successful in meeting nutritional needs.
    • Start if enteral nutrition is not able to be provided for 2 days (for whatever reason).
  • Parenteral nutrition requires central venous access.
  • Consult Nutrition to guide macronutrient and electrolyte dosing.
  • Laboratory monitoring on parenteral nutrition:
    • Baseline Basic Metabolic Panel, Magnesium level, and Phosphorous level are to be ordered prior to starting parenteral nutrition.
    • Further laboratory monitoring will be individualized at the discretion of the provider and dietitian while on TPN.
    • Finger stick blood glucose will be ordered q 6 hours.

Nutritional Monitoring:

  • Dietitian will monitor patient’s nutrition intake (via PO, enteral, or parenteral) and communicate adequacy and any changes on daily rounds.
  • Body weight
    • ICU patients are weighed daily
    • IMU and floor patients are weighed twice weekly
  • Indirect calorimetry
    • Indirect Calorimetry and Urinary Urea Nitrogen test will be re-assessed weekly when feasible and appropriate.

NPO Orders for Operating Room or other Procedures, and/or Moderate Sedation

NPO Orders for Moderate Sedation during Dressing Changes

  • Does the patient have a secured airway (endotracheal tube or tracheostomy)?
    • If yes, there is no NPO order to be placed.
    • Continue enteral nutrition until the time of moderate sedation.
  • If no, does the patient have a post-pyloric feeding tube?
    • If yes, there is no NPO order to be placed.
    • Continue enteral nutrition until the time of moderate sedation.
  • If no, patient should be made NPO 8 hours prior to planned moderate sedation (check with Burn ICU attending).
    • Bolus feeds:
      • Assess for appropriateness of bolus feeds:
        • Patient previously tolerating continuous tube feeds at goal.
        • Calculate total tube feed volume per day and divide by 5; the bolus volume should not exceed 500ml per feed.
          • I.e. only appropriate if total tube feed volume for the day is ≤2500ml/day
      • If appropriate, order bolus tube feeding:
        • Give first bolus of day 8 hours prior to scheduled moderate sedation.
        • Give second bolus of day 45 minutes after completion of moderate sedation and patient’s recovery
        • Schedule remaining 3 bolus feeds equally spaced over remainder of day.
        • Order free water flushes equally with each bolus tube feed.