Early enteral nutrition does not decrease hypermetabolism associated with burn injury. The 2002 Clinical Research Award. An evaluation of the safety of early vs delayed enteral support and effects on clinical, nutritional, and endocrine outcomes after severe burns. Differential effects of three enteral dietary regimens on selected outcome variables in burn patients. A randomized prospective trial of hyperbaric oxygen in a referral burn center population. Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Evaluating the role of alternative therapy in burn wound management: randomized trial comparing moist exposed burn ointment with conventional methods in the management of patients with second-degree burns. Enteral versus parenteral nutrition after severe closed head injury. Randomised controlled trial of psychological debriefing for victims of acute burn trauma. Fluid replacement in burned patients.
A prospective, randomized study was performed to compare the effects of early versus late enteral feeding on postburn metabolism.
                Burn patients were randomized to receive enteral feedings either within 24 hours (early) or 7 days (late) of injury. Basal energy expenditure (BEE) was calculated from Harris-Benedict equations and resting energy expenditure (REE) was obtained from indirect calorimetry. The average daily energy expenditure (DEE) was expressed as REE/BEE.
                Average age, burn size, infections, and length of stay were similar between groups. Mortality between groups was similar (early, 28%; late, 38%) and not significantly influenced by inhalation injury. When controlled for percentage of total body surface area burn, inhalation injury, and age, the early group had an increased rather than decreased DEE, with a mean DEE calorie 0.17 more than the late group (p = 0.07).
                Early enteral feeding does not decrease the average energy expenditure associated with burn injury. Early enteral support is believed to improve gastrointestinal, immunological, nutritional, and metabolic responses to critical injury; however, this premise is in need of further substantiation by definitive data. The purpose of this prospective study was to examine the effectiveness and safety of early enteral feeding in pediatric patients who had burns in excess of 25% total body surface area. Seventy-seven patients with a mean percent total body surface area burn of 52.5 +/- 2.3 (range 26-91), percent full thickness injury of 44.7 +/- 2.8 (range 0-90), and age ranging from 3.1 to 18.4 (mean 9.3 +/- 0.5) were randomized to two groups: early (feeding within 24 hours of injury) vs control (feeding delayed at least 48 hours postburn). Nutrient intake was measured daily, indirect calorimetry was performed biweekly, and blood and urine samples were obtained for the assay of cortisol, glucagon, insulin, gastrin, epinephrine, norepinephrine, dopamine, triiodothyronine, tetraiodothyronine, albumin, transferrin, prealbumin, retinol-binding protein, glucose, nitrogen balance, and 3-methylhistidine throughout the study period. Three protocol violations occurred, and two patients were transferred to another hospital; these patients were excluded from the study. No patient in either group experienced tube feeding aspiration. No differences were evident in infection, diarrhea, hospital length of stay, or mortality outcomes. A higher incidence of reportable adverse events coincided with early feeding (22 vs 8%), but this was not statistically significant. The delayed feeding group demonstrated a significant caloric deficit during postburn week (PBW) 1 (P <.0001) and PBW2 (P =.0022). Serum insulin (P =.0004) and triiodothyronine (P =.0162) were higher in the early fed group during PBW1. A decrease in 3-methylhistidine output (suggesting a decrease in protein breakdown) was also evident during PBW1 (P =.0138). No other significant trends in study outcome variables were noted. In conclusion, provision of enteral nutrients shortly after burn injury reduces caloric deficits and may stimulate insulin secretion and protein retention during the early phase postburn. These data, however, do not necessarily reaffirm the safety of early enteral feeding, nor do they associate earlier feeding with a direct improvement in endocrine status or a reduction in morbidity, mortality, hypermetabolism, or hospital stay. Future studies are needed to establish precise feeding implementation times that maximize clinical benefit while minimizing morbidity in the critically injured burn patient. A modular tube feeding recipe (MTF) was designed to meet the unique nutritional needs of burn patients, applying principles previously documented in our burned guinea pig model. MTF, a high-protein, low-fat, linoleic acid-restricted formulation is enriched with omega-3 fatty acids, arginine, cysteine, histidine, vitamin A, zinc, and ascorbic acid. Fifty patients, 3 to 76 years of age with burns ranging from 10 to 89% total body surface area were prospectively randomized into three groups which blindly compared MTF to two enteral regimens widely utilized in the nutritional support of burns. Age, percent total and third-degree burn, resting energy expenditure, and calorie and protein intake were similar in all groups. Data analysis demonstrated significant superiority of MTF in the reduction of wound infection (p less than 0.03) and length of stay/percent burn (p less than 0.02). MTF was also associated with a decreased incidence of diarrhea, improved glucose tolerance, lower serum triglycerides, reduced total number of infectious episodes and trends toward improved preservation of muscle mass, although statistical significance was not achieved. Seventy percent of deaths occurred in the group supported with an inherently large dose of fat and linoleic acid. Combining these observations, it is believed that MTF is effective in modulating an improved response to burn injury. Various studies of the effect of hyperbaric oxygen (HBO) in a wide variety of disease entities have been carried out. In the treatment of burns, animal and human studies have yielded somewhat contradictory results. Controlled studies in humans are limited. A randomized study on the effect of HBO was conducted involving 125 burn patients admitted within 24 hours of injury who were matched by age, burn size, and presence or absence of inhalation injury. Patients in the treatment arm received oxygen at two atmospheres of pressure for 90 minutes twice a day for a minimum of 10 treatments and a maximum of one treatment per total body surface per cent burn. The control group was treated in a similar fashion, except for the absence of HBO. There were no statistically significant differences between the two groups for the outcome measures of mortality, number of operations, and length of stay for the survivors. In this large clinical trial, we were unable to demonstrate any significant benefit to burn patients from the use of HBO. To determine the effect of early enhanced enteral nutrition (EN) on clinical outcome of head-injured patients.
                Prospective, randomized, controlled trial.
                Tertiary neurosurgical and trauma center.
                Eighty-two patients suffering head injury and requiring mechanical ventilation.
                Patients were randomized to receive standard EN (gradually increased from 15 mL/hr up to estimated energy and nitrogen requirements) or enhanced EN (started at a feeding rate that met estimated energy and nitrogen requirements) from day 1. Good neurologic outcome (Glasgow Outcome Scale score of 4 or 5) was determined at 3 and 6 months after injury, and the incidence of infective and total complications was determined during the hospital stay up to 6 months.
                Disease severity assessed by best preintubation Glasgow Coma Scale score, pupillary responses, Injury Severity Score, Acute Physiology and Chronic Health Evaluation II score, computed tomographic scan categorization, and age was similar in both groups. Intervention patients had a higher percentage of energy (p = .0008) and nitrogen (p<.0001) requirements met by EN in the first week after injury. Neurologic outcome at 6 months was similar between groups, but there was a tendency for more intervention patients to have a good neurologic outcome at 3 months than control patients (61% vs. 39%, p = .08). Fewer intervention patients had an infective complication (61% vs. 85%, p = .02) or more than one total complication (37% vs. 61%, p = .046) compared with control patients. Enhanced EN was associated with a reduction in the ratio of serum concentration of C-reactive protein to albumin up to day 6 after injury (p = .004).
                Enhanced EN appears to accelerate neurologic recovery and reduces both the incidence of major complications and postinjury inflammatory responses. Moist exposed burn ointment (MEBO), from China, has been said to revolutionize burn management.
                Our study was conducted to compare MEBO with conventional management (C) with respect to the rate of wound healing, antibacterial and analgesic effect, and hospital costs.
                This is a prospective, randomized, controlled clinical trial conducted between 1 March 1997 and 24 October 1998.
                The trial was conducted in a specialized burn facility located in a tertiary referral hospital in a developed and industrialized island-state in Southeast Asia.
                We randomly assigned 115 consecutive patients between the ages of 12 and 80 who had partial-thickness thermal burns covering less than 40% of body surface area (BSA) to receive either MEBO or C. Fifty-seven patients were assigned to MEBO and 58 patients to C. The latter group received twice-daily dressing changes; MEBO patients received MEBO every 4 hours.
                Patients were hospitalized until 75% BSA had healed. BSA was determined by visual inspection and charted on Lund and Browder charts regularly. Wound healing rate, bacterial infection rate, pain score, and hospitalization costs were recorded.
                The median time to 75% healing was 17.0 and 20.0 days with MEBO and C, respectively (HR = 0.67, 95% CI = 0.41-1.11, P =.11), suggesting similar efficacy between the 2 modalities. Bacterial infection rates were similar between the 2 groups (HR = 1.10, 95% CI = 0.59-2.03, P =.76). MEBO imparted a greater analgesic effect in the first 5 days of therapy and reduced hospital costs by 8%.
                MEBO is as effective as conventional management but is not the panacea for all burn wounds. The use of MEBO eases the management of face and neck burns and facilitates early institution of occupational therapy in hand burns. It confers better pain relief such that fewer opiates are used during the first 5 days after burn injury. We measured energy expenditure (MREE) and nitrogen excretion (UUN) in patients with severe head injury randomized to early parenteral (TPN, n = 21) or jejunal (ENT, n = 27) feeding with identical formulations. The MREE rose to 2400 +/- 531 kcal/day in both groups and remained at 135% +/- 26% to 146% +/- 42% of predicted energy expenditure over 4 weeks. Nitrogen excretion peaked the second week at 33.4 +/- 10 (TPN) and 31.2 +/- 7.5 (ENT) g N/day. Both routes were equally effective at meeting nutritional goals (1.2 x MREE, 2.5 g protein/kg/day intake, stabilized albumin and transferrin levels). Infections were equally frequent: 1.86 episodes/TPN patient versus 1.89 episodes/ENT patient. While patient charges were much greater for TPN, the hospital costs were similar for TPN and ENT support regimens. These findings show that patients with head injuries are hypermetabolic for weeks, that only 27% are capable of spontaneously eating nutritional requirements by discharge, and that either TPN or ENT support is equally effective when prescribed according to individual measurements of MREE and nitrogen excretion. Psychological debriefing (PD) is widely used following major traumatic events in an attempt to reduce psychological sequelae.
                One hundred and thirty-three adult burn trauma victims entered the study. After initial questionnaire completion, participants were randomly allocated to an individual/couple PD group or a control group who received no intervention; 110 (83%) were interviewed by an assessor blind to PD status three and 13 months later.
                Sixteen (26%) of the PD group had PTSD at 13-month follow-up, compared with four (9%) of the control group. The PD group had higher initial questionnaire scores and more severe dimensions of burn trauma than the control group, both of which were associated with a poorer outcome.
                This study seriously questions the wisdom of advocating one-off interventions post-trauma, and should stimulate research into more effective initiatives. Burn injury involves a large amount of water, electrolytes and proteins loss trough the burn wound. For this reason, to avoid shock, a wide infusion of fluid is necessary in the first hours after trauma. Many reanimation formulas were proposed in the past years, with different composition: saline, colloids, plasma. The authors have studied 40 burned patients admitted in Verona Burn Center within 4 hours after burn, with burns over 30% of the body surface area. Twenty of them were treated with Baxter reanimation formula (ringer lactated saline, RLS) while the others with Monafo hypertonic lactated saline (HLS), modified by Milan Burn Center. The two randomized groups were assessed and compared. In RLS group total fluid volume infused was higher while sodium requirements was lower than in HLS patients, with statistically significative difference (p < 0.01). On the contrary, in HLS group, potassium administered was perhaps twice if compared with the other. Haematocrit, urine output and urine osmolarity were adequate in both the groups, and did not showed statistical differences, such as serum proteins concentration, that was low in all patients, while a significative difference was noted in urine osmolarity (p < 0.01). A metabolic alkalosis was present in HLS patients, while, on the other hand, serum nitrogen was significantly higher (p < 0.05), in the first 48 hours after burn, in RLS group. Patients were assessed for pre-existing diseases too, and data showed that complications were lower in HLS than in RLS group. HLS resuscitation formula guarantees a good electrolytes balance with lower fluid load, reducing tissue oedema and complication rate. Mortality rate was higher in HLS, may be for an higher Roy index in this group.
This systematic review has not found sufficient evidence to support or refute the effectiveness of early versus late enteral nutrition support in adults with burn injury. The trials showed some promising results that would suggest early enteral nutrition support may blunt the hypermetabolic response to thermal injury, but this is insufficient to provide clear guidelines for practice. Further research incorporating larger sample sizes and rigorous methodology that utilises valid and reliable outcome measures, is essential.