Early Enteral Nutrition in Burns: Compliance With Guidelines and Associated Outcomes in a Multicenter Study

Abstract

Early nutritional support is an essential component of burn care to prevent ileus, stress ulceration, and the effects of hypermetabolism. The American Burn Association practice guidelines state that enteral feedings should be initiated as soon as practical. The authors sought to evaluate compliance with early enteral nutrition (EN) guidelines, associated complications, and hospitalization outcomes in a prospective multicenter observational study. They conducted a retrospective review of mechanically ventilated burn patients enrolled in the prospective observational multicenter study “Inflammation and the Host Response to Injury.” Timing of initiation of tube feedings was recorded, with early EN defined as being started within 24 hours of admission. Univariate and multivariate analyses were performed to distinguish barriers to initiation of EN and the impact of early feeding on development of multiple organ dysfunction syndrome, infectious complications, days on mechanical ventilation, intensive care unit (ICU) length of stay, and survival. A total of 153 patients met study inclusion criteria. The cohort comprised 73% men, with a mean age of 41 ± 15 years and a mean %TBSA burn of 46 ± 18%. One hundred twenty-three patients (80%) began EN in the first 24 hours and 145 (95%) by 48 hours. Age, sex, inhalation injury, and full-thickness burn size were similar between those fed by 24 hours vs after 24 hours, except for higher mean Acute Physiology and Chronic Health Evaluation II scores (26 vs 23, P = .03) and smaller total burn size (44 vs 54% TBSA burn, P = .01) in those fed early. There was no significant difference in rates of hyperglycemia, abdominal compartment syndrome, or gastrointestinal bleeding between groups. Patients fed early had shorter ICU length of stay (adjusted hazard ratio 0.57, P = 0.03, 95% confidence interval 0.35–0.94) and reduced wound infection risk (adjusted odds ratio 0.28, P = 0.01, 95% confidence interval 0.10–0.76). The investigators have found early EN to be safe, with no increase in complications and a lower rate of wound infections and shorter ICU length of stay. Across institutions, there has been high compliance with early EN as part of the standard operating procedure in this prospective multicenter observational trial. The investigators advocate that initiation of EN by 24 hours be used as a formal recommendation in nutrition guidelines for severe burns, and that nutrition guidelines be actively disseminated to individual burn centers to permit a change in practice.

Evaluación Del Indicador Clínico De Calidad ‘Nutrición Enteral Precoz’ en Servicios De Medicina Intensiva

“…Algunas series de pacientes críticos han reportado tasas de instauración precoz (< 48 h) de la NE entre el 50% y el 95%, aun cuando la monitorización reglada de este aspecto no constituía el objetivo de los distintos estudios (20,21). La tasa más elevada del 95% se observó en un grupo homogéneo de grandes quemados.…”

Effects of Nutritional Supplementation on Prealbumin Concentrations in Pediatric Burn Patients: A Randomized, Controlled Trial

“…The Canadian Clinical Practice Guidelines recommend starting EN within 24 to 48 hours after admission to the intensive care unit in critically ill patients [9]. Early enteral nutritional support in severe burns has demonstrated numerous advantages, such as increased caloric intake, insulin secretion and protein retention, improved bowel mucosal integrity, and decreased incidence of stress gastritis [10].…”

Checklist and Decision Support in Nutritional Care for Burned Patients

“…For example, it attenuates the hypermetabolic state, improves wound healing, decreases catabolism, and increases the chance of survival. 7,8,25,26 Since nutrition plays such a substantial role to burn patients, it is imperative that adequate formulas be utilized and daily monitoring of total intake, not just rate delivered hourly, be performed.…”