International observational study of nutritional support in mechanically ventilated patients following burn injury

Glutamine Supplementation on Burn Patients: A Systematic Review and Meta-analysis

To evaluate the effect of glutamine supplement on patients with burns, we conducted a systematic review and meta-analysis via synthesizing up-to-date studies. Databases including PubMed, Cochrane Central Register, EMBASE, Google scholar, Wanfang data, and ClinicalTrials.gov were searched up to October 2023 to find randomized trials evaluating glutamine supplement on patients with burns. The main outcomes included hospital stay, in-hospital mortality, infection, and wound healing. Twenty-two trials that randomized a total of 2170 patients were included in this meta-analysis. Pooled the length of hospital stay was shortened by glutamine supplement (weighted mean differences [WMD] = -7.95, 95% confidence interval [CI] -10.53 to -5.36, I2 = 67.9%, 16 trials). Both pooled wound healing rates (WMD = 9.15, 95% CI 6.30 to 12.01, I2 = 82.7%, 6 studies) and wound healing times (WMD = -5.84, 95% CI -7.42 to -4.27, I2 = 45.7%, 7 studies) were improved by glutamine supplement. Moreover, glutamine supplement reduced wound infection (risk ratios [RR] = 0.38, 95% CI 0.21 to 0.69, I2 = 0%, 3 trials), but not nonwound infection (RR = 0.88, 95% CI 0.73 to 1.05, I2 = 39.6%, 9 trials). Neither in-hospital mortality (RR = 0.95, 95% CI 0.74 to 1.22, I2 = 36.0%, 8 trials) nor the length of intensive care unit stay (WMD = 1.85, 95% CI -7.24 to 10.93, I2 = 78.2%, 5 studies) was improved by glutamine supplement. Subgroup analysis showed positive effects were either influenced by or based on small-scale, single-center studies. Based on the current available data, we do not recommend the routine use of glutamine supplement for burn patients in hospital. Future large-scale randomized trials are still needed to give a conclusion about the effect of glutamine supplement on burn patients.

Higher serum prealbumin levels are associated with higher graft take and wound healing in adult burn patients: A prospective observational trial

INTRODUCTION

Nutritional support is essential in burn care. There are few studies investigating the effect of nutrition on burn healing. The purpose of this study was to determine the relationship between perioperative serum prealbumin levels and the probability of autologous skin graft take in burned patients.

MATERIALS AND METHODS

A prospective observational study was carried out with burned adults recruited consecutively from April 2019 until September 2021. Serum prealbumin was determined perioperatively. The percentage of graft take was evaluated over the first 5 postoperative dressing changes. Time until full epithelialization (absence of wounds) was also registered.

RESULTS

A total of 60 patients were recruited, mostly middle-aged people with moderate flame burns. Serum prealbumin levels and graft take had a weak-moderate, nonlinear, statistically significant correlation. They were also an independent predictor of full epithelialization on the fifth dressing change, together with burn depth. Higher perioperative serum prealbumin levels were significantly associated with a reduction in time until full epithelialization.

CONCLUSIONS

Perioperative serum prealbumin levels are significantly correlated with the probability of split-thickness skin autograft take in burned patients and with a reduced time to achieve complete epithelialization. They were an independent predictor of full graft take.

Documented nutritional therapy in relation to nutritional guidelines post burn injury - a retrospective observational study

BACKGROUND & AIMS

Intensive nutritional therapy is an essential component of burn care. Regarding post-minor burn injuries, the literature is lacking. The aim of this study was to evaluate documented nutritional therapy in relation to international guidelines after both minor and major burn injuries. The secondary aim of this study was to evaluate the adequacy of energy and protein intake compared to individual nutritional goals post-burn injury.

METHODS

A retrospective observational single-centre study including patients admitted between 2017 and 2019 at a burn centre in Sweden was performed. The patients included in the study were ≥18 years old and in need of hospital care for ≥72 h post-burn injury. Information about patients' demographics, nutritional therapy, and clinical characteristics of burn injury was collected. The patients were divided according to total body surface area burnt (TBSA %) into minor burn injuries (TBSA <20%) and major burn injuries (TBSA ≥20%). Descriptive statistics were used to analyse data. Adherence to guidelines was established by comparing 24 nutritional therapy recommendations to documented treatment. If documented nutritional treatment were in accordance with guidelines, adherence was considered high (≥80%), moderate (60-79.9%) or low (<59.9%).

RESULTS

One hundred thirty-four patients were included, 90 patients with minor burn injuries and 44 patients with major burn injuries. Documented adherence to the nutritional guideline was overall low. After minor burn injury, 8% (2/24) of nutritional therapy recommendations had a high adherence (fat intake <35% of total energy intake and enteral nutrition as prioritized feeding route), 17% (4/24) a moderate adherence, and 75% (18/24) a low adherence. In patients treated after a major burn injury, there were two recommendations with documented high adherence (Vitamin C and Zinc); 25% (6/24) had moderate adherence, and 67% (16/24) had low adherence. In addition, quite a large amount of missing data was found. Adequacy of documented nutritional intake, compared to the individual documented goal, was 78% (±23%) for energy and 66% (±22%) for protein after minor burn injury. After major burn injury, the adequacy was 89% (±21%) for energy and 78% (±19%) for protein, respectively.

CONCLUSIONS

This study revealed low adherence to nutritional guidelines in patients treated for minor and major burn injuries. Compared to major burn injuries, lower documented adequacy for both energy and proteins was found in minor burn injuries. Given the disparity between guidelines and documented nutritional therapy, and the lack of specific guidelines for minor burn injuries, there could be a considerable risk of inadequate nutritional therapy post-burn injury.

Fasting practices of enteral nutrition delivery for airway procedures in critically ill adult patients: A scoping review

BACKGROUND

There is limited understanding of fasting practices and reported safety concerns for airway procedures in critically ill adults.

OBJECTIVE

To describe fasting practices including safety concerns for airway procedures in critically ill adult patients in the reported literature.

INCLUSION CRITERIA

Studies conducted in adult critically ill patients receiving enteral nutrition (EN) and undergoing an airway procedure (endotracheal intubation, endotracheal extubation, and tracheostomy) were included if EN fasting practices and/or prespecified nutrition and clinical outcomes were reported.

METHODS

A scoping review using the Joanna Briggs Institute methodology was conducted. MEDLINE, Embase, and CINAHL were searched from 2000 to January 19, 2022. Results are presented via narrative synthesis.

RESULTS

Fourteen studies were included, with only one randomised control trial (RCT). Twelve studies reported on fasting practices with varied EN fasting durations (0-34 h) and two reported data on nutrition adequacy. Three studies investigated continued EN in one study arm and four studies minimised fasting duration by including gastric suctioning prior to the airway procedure. Safety concerns primarily related to aspiration events (61%) were reported in nine studies.

CONCLUSION

In the reported literature, there is wide variation in EN fasting practices for airway procedures in critically ill patients with limited evidence to inform practice.

A Randomized Trial of Enteral Glutamine for Treatment of Burn Injuries

BACKGROUND

Glutamine is thought to have beneficial effects on the metabolic and stress response to severe injury. Clinical trials involving patients with burns and other critically ill patients have shown conflicting results regarding the benefits and risks of glutamine supplementation.

METHODS

In a double-blind, randomized, placebo-controlled trial, we assigned patients with deep second- or third-degree burns (affecting ≥10% to ≥20% of total body-surface area, depending on age) within 72 hours after hospital admission to receive 0.5 g per kilogram of body weight per day of enterally delivered glutamine or placebo. Trial agents were given every 4 hours through a feeding tube or three or four times a day by mouth until 7 days after the last skin grafting procedure, discharge from the acute care unit, or 3 months after admission, whichever came first. The primary outcome was the time to discharge alive from the hospital, with data censored at 90 days. We calculated subdistribution hazard ratios for discharge alive, which took into account death as a competing risk.

RESULTS

A total of 1209 patients with severe burns (mean burn size, 33% of total body-surface area) underwent randomization, and 1200 were included in the analysis (596 patients in the glutamine group and 604 in the placebo group). The median time to discharge alive from the hospital was 40 days (interquartile range, 24 to 87) in the glutamine group and 38 days (interquartile range, 22 to 75) in the placebo group (subdistribution hazard ratio for discharge alive, 0.91; 95% confidence interval [CI], 0.80 to 1.04; P = 0.17). Mortality at 6 months was 17.2% in the glutamine group and 16.2% in the placebo group (hazard ratio for death, 1.06; 95% CI, 0.80 to 1.41). No substantial between-group differences in serious adverse events were observed.

CONCLUSIONS

In patients with severe burns, supplemental glutamine did not reduce the time to discharge alive from the hospital. (Funded by the U.S. Department of Defense and the Canadian Institutes of Health Research; RE-ENERGIZE ClinicalTrials.gov number, NCT00985205.).

Safety and benefits of intraoperative enteral nutrition in critically ill pediatric burn patients: A systematic review and pooled analysis

Burn injuries significantly increase a patient's metabolic demand. Adequate nutrition is essential as an adjunct to recovery and reducing morbidity and mortality. In contrast to adults, this is especially important for pediatric patients who have limited reserves and are in a period of growth. Burn patients often require multiple anesthetic procedures that are accompanied by standard perioperative fasting periods that result in substantial nutritional interruptions. Continuous intraoperative feeding has been proposed as a solution, but there is no current consensus on its role and safety, particularly in the pediatric population. Thus, the goal of this study was to examine the safety and benefits of intraoperative nutrition in critically-ill pediatric burn injured patients. A systematic review of MEDLINE, PubMed, Scopus, and Web of Science was conducted using the following terms: feeding or enteral or nutrition or fasting and adolescent or youth or pediatric or child or teen and burn or thermal injury or fire. The primary outcome was incidence of aspiration. Secondary outcomes included patient nutritional status (caloric deficit and weight), wound healing, days spent in the intensive care unit, ventilator days, pneumonia, number of surgeries, length of hospital stay, and mortality. Pooled analyses of binary outcomes were computed. Four studies consisting of 496 patients, met inclusion criteria. All studies were level IV evidence, but had high methodological quality. The median burn total body surface area (TBSA) was 43.8% (IQR 33.4-58.8%), with a median of 30% of patients having an inhalational injury. Patients underwent a median of 4.2 surgeries (IQR 1.8-7.4). Intraoperative feeding was conducted through nasoduodenal tubes. There were no aspiration events. Pooled analysis demonstrated that there were no differences in rates of aspiration, pneumonia, or wound infection (p>0.05) between patients who were intraoperatively fed and those who were not. Those fed intraoperatively had significantly more surgeries, ventilator days, longer hospital stays, but lower mortality (p<0.05). There was large heterogeneity in nutritional assessment methods. Intraoperatively fed patients had an average gain of 144.4 kcal/kg,1.7 days of exclusive enteral nutrition (vs. loss of -119.1 kcal/kg and -1.4 days), and a cumulative positive caloric balance of +2673kcal ±2147 (vs. loss of -7899kcal ±3123) compared to those with interrupted feeding. Continuous intraoperative duodenal feeding during burn surgery appears to be safe in the pediatric burn population, with no reported episodes of aspiration. Uninterrupted feeding was also associated with weight maintenance and reduced caloric deficit. It may also have a survival benefit, as continuously fed patients needed more surgeries and intensive/hospital care, but had decreased mortality.

Small bowel feeding: do you pay the price for bypassing the stomach?

PURPOSE OF REVIEW

Hydration and nutritional support is a vital part of medical care, thus a clear understanding of the optimal approach is vital for medical professionals. This is a particularly pertinent issue for patients admitted to a critical care setting. This article aims to define the advantages and disadvantages of gastric and postpyloric feeding in the critical care setting, thus aiding decision-making for clinicians.

RECENT FINDINGS

Within the article, the main themes covered are those relating to enteral feeding tube placement, the impact of enteral feeding route on ventilator-associated pneumonia, optimization of enteral tube feeding in critical care and the impact that a chosen route may have upon gastrointestinal function.

SUMMARY

The value of enteral feeding in critical illness is proven beyond doubt and the simplest approach has long been 'if the gut works, use it'. If gastric feeding is not able to be established or is not tolerated then jejunal feeding should be considered as a preferable alternative to parenteral nutrition. Improving access to service or techniques for postpyloric tube placement would assist in optimizing nutritional support in the critical care setting.

Use of the Braden Scale to Predict Injury Severity in Mass Burn Casualties

Background

Mass burn casualties impose an enormous burden on triage systems. The triage capacity of the Braden Scale for detecting injury severity has not been evaluated in mass burn casualties.

Material/Methods

The New Injury Severity Score (NISS) was used to dichotomize the injury severity of patients. The Braden Scale and other potentially indicative measurement tools were evaluated using univariate analysis and multivariate logistic regression. The relationships between the Braden Scale and other continuous variables with injury severity were further explored by correlation analysis and fitted with regression models. Receiver operating characteristic (ROC) curve analysis was used to validate triage capacity and compare prognostic accuracy.

Results

A total of 160 hospitalized patients were included in our study; 37 were severely injured, and 123 were not. Injury severity was independently associated with the Numerical Rating Scale (adjusted OR, 1.816; 95% CI, 1.035–3.187) and Braden Scale (adjusted OR, 0.693; 95% CI, 0.564–0.851). The ROC curve of the fitted quadratic model of the Braden Scale was 0.896 (0.840–0.953), and the cut-off value was 17. The sensitivity was 81.08% (64.29–91.44%) and the specificity was 82.93% (74.85–88.89%). Comparison of ROC curves demonstrated an infinitesimal difference between the Braden Scale and NISS for predicting 30-day hospital discharge (Z=0.291, P=0.771) and Intensive Care Unit admission (Z=2.016, P=0.044).

Conclusions

The Braden Scale is a suitable triage tool for predicting injury severity and forecasting disability-related outcomes in patients affected by mass burn casualty incidents.

Nutrition and Gastrointestinal Dysmotility in Critically Ill Burn Patients: A Retrospective Observational Study

BACKGROUND

Gastrointestinal (GI) dysmotility impedes nutrient delivery in critically ill patients with major burns. We aimed to quantify the incidence, timing, and factors associated with GI dysmotility and subsequent nutrition delivery.

METHODS

A 10-year retrospective observational study included mechanically ventilated, adult, critically ill patients with ≥15% total body surface area (TBSA) burns receiving nutrition support. Patients with a single gastric residual volume ≥250 mL were categorized as having GI dysmotility. Daily medical and nutrition data were extracted for ≤14 days in the intensive care unit (ICU). Data are mean (SD) or median (interquartile range). Factors associated with GI dysmotility and the effect on nutrition and clinical outcomes were assessed.

RESULTS

Fifty-nine patients were eligible; 51% (n = 30) with GI dysmotility and 49% (n = 29) without. Baseline characteristics (dysmotility vs no dysmotility) were age (48 [33-60] vs 34 [26-46] years); Acute Physiology and Chronic Health Evaluation II score (16 [12-17] vs 13 [10-16]); sex ([men] 80% vs 86%); and TBSA (49% [35%-59%] vs 38% [26%-55%]). Older age was associated with increased probability of dysmotility (P = .049). GI dysmotility occurred 32 (19-63) hours after ICU admission but was not associated with reduced nutrient delivery. Postpyloric tube insertions were attempted in 83% (n = 25) of patients, with 72% (n = 18) being successful. Postpyloric feeding achieved higher nutrition adequacy than gastric feeding (energy: 82% [95% CI, 70-94] vs 68% [95% CI, 63-74], P = .036; protein: 75% [95% CI, 65-86] vs 61% [95% CI, 56-65], P = .009).

CONCLUSION

GI dysmotility occurs early in critically ill burn patients, and postpyloric feeding improves nutrition delivery.

The Pediatric Burn: Current Trends and Future Directions

Management of the pediatric burn patient presents a variety of clinical challenges for the pediatric anesthesiologist. Despite the high incidence of burn injuries, standard management strategies are far from universal. The complex physiologic changes presented by burn injuries present airway management and resuscitation challenges and mandate careful consideration of adequate nutritional support. Long hospital stays with frequent operations and dressing changes necessitate creative approaches to anxiolysis and pain control. Underutilized modalities warranting further research include regional anesthesia and nonpharmacologic approaches, such as virtual reality. Further research and collaboration between burn centers are needed to standardize care for this population.

How long are mechanically ventilated patients fasted prior to surgery? An exploratory study examining preoperative fasting practices across trauma centres

For mechanically ventilated patients undergoing surgery, interrupting enteral feeding to prevent pulmonary aspiration is common; however, there are no published preoperative fasting guidelines for these patients, resulting in fasting practices that often vary greatly between hospitals. This retrospective study described fasting practices and surgical outcomes of mechanically ventilated patients across five trauma centres. The primary exposure was hours nil per os before surgery and was stratified into short (<6h) and moderate (≥6h) fasting duration. Shared frailty models assessed the relationship between time to perioperative complication and nil per os category. Three of the five hospitals had preoperative fasting guidelines, and those most compliant required patients to be fed up until surgery. Most patients were fasted ≥6h prior to surgery and no increased risk of complication was found for patients who were fasted <6h. Future studies are needed to establish appropriate preoperative fasting thresholds for mechanically ventilated patients.

Pediatric burn resuscitation, management, and recovery for the pediatric anesthesiologist

PURPOSE OF REVIEW

The purpose of this article is to summarize literature in pediatric burn resuscitation and management that is relevant to the pediatric anesthesiologist. The scope of the literature is expanding as long-term survival in even the most critically ill, burn-injured children has increased.

RECENT FINDINGS

Longstanding variations in the care of burn-injured children exist despite decades of experience in burn care management. There seems to be a discomfort outside major burn centers in the triage, evaluation, and assessment of burned children. This is evidenced by the prevalence of 'unnecessary intubations', continued overestimation of total body surface area injured, and subsequent fluid administration disproportionate to injury leading to over-resuscitation. Techniques, such as virtual reality and regional anesthesia are increasingly available and serve adjuncts to pharmacologic therapies for anxiolysis and analgesia. Such techniques reduce opioid utilization while maintaining patient comfort and satisfaction particularly during wound dressing changes. Questions about transfusion threshold and ratio of blood products remain topics of ongoing research.

SUMMARY

Literature review continues to reveal underpowered or retrospective analyses of these very important questions. Public health burden caused by burns warrants rigorous, prospective studies to take the best care of these patients and portend the best long-term outcomes. Collaboration amongst pediatric anesthesiologists who care for these children is necessary to develop and execute powered studies to answer important questions.

Evaluating the Safety and Efficacy of Intraoperative Enteral Nutrition in Critically Ill Burn Patients: A Systematic Review and Meta-analysis

Major burn injuries incite a hypermetabolic response, and the initiation of early enteral nutrition is the standard of care in patients with large burns and contributes to improved outcomes. Perioperative fasting is a common cause of caloric deficits in burn patients and can be obviated with intraoperative enteral nutrition. However, the risks and benefits of this practice are unknown, and there is a concern for aspiration. We conducted a systematic review and meta-analysis to evaluate the safety and efficacy of intraoperative enteral nutrition. We performed a systematic literature search using PubMed, Scopus, and OvidSP MEDLINE databases. We identified studies that evaluated the effects of intraoperative enteral nutrition in adult burn patients compared to those undergoing routine perioperative fasting. We performed a meta-analysis on the incidence of mortality, pneumonia, wound infections, and aspiration in burn patients receiving intraoperative enteral nutrition. We identified seven articles for qualitative review and four for quantitative review (N = 83 patients). There were no statistically significant increases in the risk of mortality (odds ratio [OR] = 1.28, 95% confidence interval [CI]: 0.49, 3.31), wound infections (OR = 0.71, 95% CI: 0.16, 3.24), pneumonia (OR = 2.1, 95% CI: 0.7, 6.1), and aspiration (OR = 1.14, 95% CI: 0.07, 18.75) in patients receiving intraoperative enteral nutrition. Within individual studies, intraoperative enteral nutrition patients received significantly more calories than standard fasting patients. Intraoperative enteral nutrition may increase nutritional intake in burn patients without an increase in complications; however, this is based on limited studies. Randomized controlled trials are needed before recommendations on intraoperative enteral nutrition practice can be made.

The effect of a hydrolyzed collagen-based supplement on wound healing in patients with burn: A randomized double-blind pilot clinical trial

INTRODUCTION

Burn is among the most severe forms of critical illness, associated with extensive and prolonged physical, metabolic and mental disorders. The aim of this study was to assess the effect of an oral, low-cost, and accessible collagen-based supplement on wound healing in patients with burn.

METHODS

In this randomized double-blind controlled pilot clinical trial, 31 men, 18-60years, with 20-30% total body surface area burn were studied. Patients were randomly assigned to receive either a collagen-based supplement (1000kcal) or an isocaloric placebo, for 4 weeks. Serum pre-albumin, rate of wound healing, length of hospital stay, and anthropometries were assessed at baseline, and the end of week 2 and 4.

RESULTS

Serum pre-albumin was significantly higher at week 2 (29.7±13.6 vs. 17.8±7.5mg/dL, P=0.006) and week 4 (35.1±7.6 vs. 28.3±8.2mg/dL, P=0.023) in collagen than control group. Changes in pre-albumin concentration were also significantly higher in collagen group at week 2 (13.9±9.8 vs. -1.9±10.3mg/dL, P<0.001) and week 4 (19.2±7.5 vs. 8.5±10.1mg/dL, P=0.002). The Hazard ratio of wound healing was 3.7 times in collagen compared to control group (95% CI: 1.434-9.519, P=0.007). Hospital stay was clinically, but not statistically, lower in collagen than control group (9.4±4.6 vs. 13.5±7 days, P=0.063). There were no significant differences in weight, body mass index, dietary energy and protein intakes between the two groups.

CONCLUSION

The findings showed that a hydrolyzed collagen-based supplement could significantly improve wound healing and circulating pre-albumin, and clinically reduce hospital stay in patients with 20-30% burn.

Interrupted Nutrition Support in Patients With Burn Injuries: A Single-Centre Observational Study

Background

Enteral nutrition (EN) is essential to meet the increased metabolic requirements of burn-injured patients. However, feeds are often suspended for care. This study examines the interruptions in EN (IEN).

Objective

To determine the frequency and duration of IEN and whether these interruptions are predictable or unpredictable.

Design

This retrospective chart review of 27 adult burn patients examined age, sex, body mass index, percentage of total body surface area, length of hospital stay, predicted energy requirements from equations and indirect calorimetry, EN start time, time EN reached goal rate, and interruptions to EN.

Results

Predictable interruptions accounted for 74.5% (frequency) and 81.6% (duration) of total interruptions. The most frequent and time-consuming interruptions were perioperative period, extubation, and tests/procedures (predictable) versus high gastric residual volume, emesis/nausea, and feeding tube displacement (unpredictable).

Conclusions

Most IEN were due to predictable events. Based on these findings, compensating for predictable interruptions to meet nutritional requirements in burn patients is recommended.

Nutrition: reducing the hypermetabolic response to thermal injury

Nutritional support is seen as a vital component in the battle to attenuate the extreme hypermetabolic response experienced by patients suffering from large thermal injuries. Protein catabolism precipitating protein malnutrition places patients at greater risk of wound infection and sepsis due to delayed wound healing. Underfeeding, aggressive feeding, feeding routes, timing of initiation of feeding and tight insulin control have all been explored extensively in the quest to understand what nutritional treatment will best attenuate the hypermetabolic response. Despite this it is suggested that the majority of patients with large thermal injuries do not receive adequate nutritional support immediately post injury. Nurses have a pivotal role to play in ensuring that thermal injury patients receive appropriate nutritional support based on the best available evidence.

Effectiveness and safety of perioperative enteral feeding in patients with burn injuries: a systematic review protocol

OBJECTIVE

The objective of this review is to determine whether perioperative enteral feeding improves outcomes in patients with burns.

INTRODUCTION

Literature has identified many positive benefits of nutrition support for patients with burn injuries, including preservation of lean body mass, improved wound healing, reduced gastrointestinal permeability and enhanced immunity. Fasting for surgery can undermine the nutritional care of these patients by causing nutrient deficits. It may also negatively affect patient well-being and insulin resistance. Perioperative fasting is intended to protect patients from regurgitation and pulmonary aspiration. This research aims to investigate whether perioperative feeding impacts outcomes in patients with burn injuries.

INCLUSION CRITERIA

This systematic review will consider studies whose participants have a burn injury. The intervention is perioperative enteral feeding (either intragastric or post-pyloric). Patients who received perioperative feeding will be compared with patients who had enteral nutrition withheld during the perioperative period. A number of outcome measures will be investigated, including mortality, length of stay, wound infection, wound healing rate and aspiration pneumonia.

METHODS

The key databases searched will be PubMed, CINAHL, Embase, Web of Science and Cochrane Central Register of Controlled Trials and Scopus. Only studies published in English will be considered. There will be no date limits. Full texts of selected studies will be retrieved and assessed against inclusion criteria. Studies that do not meet the inclusion criteria will be excluded, with reasons provided. Data synthesis will be pooled in a statistical meta-analysis. Subgroup analysis will be conducted where possible. Where statistical pooling is not possible, the findings will be presented in narrative form.

SYSTEMATIC REVIEW REGISTRATION NUMBER

PROSPERO CRD42018119034.

Safety and efficacy of intraoperative gastric feeding during burn surgery

BACKGROUND

Large burns are associated with a dramatic increase in metabolic demand, and adequate nutrition is vital to prevent poor wound healing and septic complications. However, enteral nutrition (EN) support is frequently withheld perioperatively, risking nutritional deficits. We retrospectively examined the safety and feasibility of continuing EN during surgery in patients with an established airway, and estimated the impact of perioperative fasting on overall caloric intake.

METHODS

Mechanically ventilated patients admitted to our urban, verified burn center between January 2012 and July 2017 with greater than 20% total body surface area (TBSA) burns were included in this retrospective analysis. The total volume of EN received by the patient during each 24-h period and goal EN volume as determined by a clinical dietitian were collected.

RESULTS

A total of 45 patients met criteria with mean TBSA of 44% (range 20-84%). Most patients had a gastric feeding tube (86%). Each patient underwent a median of 4 operations (range 1-33) for a total of 249 operative days and 991 non-operative days. There were no aspiration events. On non-operative days, patients met 85% of estimated caloric needs. EN was held on 170 operative days (69%), and on these days, only 34% of total caloric needs were met. EN was continued on 77 operative days (31%), and on these days, 95% of total caloric needs were met (p<0.001). Patients who had EN held for at least 50% of operative procedures (n=30) met only 69% of caloric goals while intubated. By comparison, patients who had EN continued for a majority of procedures (n=15) met 81% of caloric goals (p=0.002).

CONCLUSIONS

Continuing EN intraoperatively in patients with an established airway appears to be a safe and efficacious way to meet patients' nutritional needs, including when feeding is delivered via a gastric route. This is particularly important given that placement of nasojejunal feeding tubes can be difficult, particularly in resource-poor settings where endoscopic or fluoroscopic-guided placement may not be practical.

Volume-Based vs Rate-Based Enteral Nutrition in the Intensive Care Unit: Impact on Nutrition Delivery and Glycemic Control

BACKGROUND

Underfeeding with enteral nutrition (EN) is prevalent in intensive care units (ICUs) and associated with negative outcomes. This study evaluated the impact of volume-based EN (VBEN) vs rate-based EN (RBEN) on delivery of prescribed energy and protein, and glycemic control (GC).

METHODS

This retrospective study included adult patients who require mechanical ventilation within 48 hours of ICU admission and with an RBEN (n = 85) or VBEN (n = 86) order for ≥3 consecutive days during the first 12 ICU days.

RESULTS

Patients receiving VBEN, vs RBEN, received more prescribed energy (RBEN, 67.6%; VBEN, 79.6%; P < .001) and protein (RBEN, 68.6%; VBEN, 79.3%; P < .001). Multiple linear regression analyses confirmed VBEN was significantly associated with an 8.9% increase in energy (P = .002) and 7.7% increase in protein (P = .004) received, after adjusting for age, Acute Physiology and Chronic Health Evaluation II score, duration of and initiation day for EN, and ICU admission location. Presence of hyperglycemia (P = .40) and glycemic variability (GV) (P = .99) were not different between the 2 groups. After adjusting for age, body mass index, diabetes history, primary diagnosis, and percent of days receiving corticosteroids, GC outcomes (presence of hyperglycemia, P = .27; GV, P = .67) remained unrelated to EN order type in multivariable regression models.

CONCLUSION

VBEN, compared with RBEN, was associated with increased energy and protein delivery without adversely affecting GC. These results suggest VBEN is an effective, safe strategy to enhance EN delivery in the ICU.

Measuring gastric residual volumes in critically ill burn patients - A systematic review

PURPOSE

Measuring gastric residual volumes (GRV) is common in intensive care units (ICU) in patients receiving enteral nutrition (EN) and are a common source of feeding interruptions. Interruptions in EN yield adverse outcomes and are an area of improvement in burn care. The objectives of this study are to summarize the literature's ICU GRV practices and offer practical suggestions to GRV management in the burn patient.

METHODS

PubMed, SCOPUS, and OvidSP Medline were systematically reviewed using the keywords: burns; thermal injury; gastric residual volume; enteral feeding; tube feeding; enteral nutrition; gastric intolerance; ICU; critical illness. Reviews, case reports, and consensus and opinion papers were excluded.

RESULTS

26 articles were identified. Six burn-specific studies were identified. GRV practices vary widely and are a common cause of EN interruption. Elevated GRVs do not equate to gastrointestinal intolerance and do not always reflect aspiration risk.

CONCLUSIONS

We advocate a GRV threshold of 500mL should be used to optimize the benefits of EN in burn ICUs. A single incident of elevated GRVs should not mandate immediate EN rate reduction or cessation but should prompt a thoughtful examination of secondary causes of gastrointestinal intolerance. Randomized controlled trials are needed to define the ideal GRV threshold and re-evaluate its role in burn care.

Acute intensive care unit management of mustard gas victims: the Turkish experience. Cutan Ocul Toxicol 2018;37:332-337. [PMID: 29648477 DOI: 10.1080/15569527.2018.1464018]

PURPOSE

Sulphur mustard (SM) is an highly toxic and vesicant chemical weapon that was used in various military conflicts several times in the history. The severity of ocular, dermal, and pulmonary symptoms that may appear following a characteristic asymptomatic period are depending on the SM concentration and exposure duration. The aim of this study is to present the clinical features and share the intensive care unit (ICU) experiences for the medical management of mustard gas victims.

MATERIALS AND METHODS

Thirteen Free Syrian Army soldiers near Al-Bab region of North Syria were reportedly exposed to oily blackish smoke with garlic smell due to the explosion of a trapped bomb without causing any blast or thermal effect on 26th November 2016. None of them wore any chemical protective suits or gas masks during explosion. Since they observed skin lesions including bullous formation next day, they were admitted to the Turkish Field Hospital at the Turkish - Syrian border and then evacuated to the State Hospital of Gaziantep Province, Turkey for further management. Eight victims who were very close to point of explosion suffered burning eyes, sore throat, dry cough and dyspnoea after the chemical attack.

RESULTS

On admission to hospital, all cases had conjunctivitis, hoarseness and bullae on various body areas. Blepharospasm and opacity were found in 8 patients and 5 of them had corneal erosions and periorbital oedema. Temporary loss of vision in 4 cases lasted for 24 h. Multiple fluid-filled blisters were observed especially on the scalp, neck, arms and hands, where direct skin exposure to the agent occurred. A definitive clinical care and infection prophylaxis measures along with the burn treatment and bronchodilators for respiratory effects were applied in ICU. Two patients received granulocyte-colony-stimulating factor due to the SM-mediated bone marrow suppression on the 16th day of exposure and one of them died because of necrotic bronchial pseudomembrane obstruction resulting in cardiopulmonary arrest.

CONCLUSIONS

SM was first used during the First World War and it is still considered one of the major chemical weapons recently used by non-state actors in Syria and Iraq. In case of SM exposure, medical treatment of SM-induced lesions is symptomatic because no antidote or causal therapy does exist even though SM is very well known for over 100 years. However, clinical management in intensive care medicine of SM victims have improved since the 1980s, this study which is one of the largest recent SM-exposed case series since that time is important for the contribution to the clinical experience.

Nutrition in burn injury: any recent changes?

PURPOSE OF REVIEW

After major progress in the 1980s of burn resuscitation resulting, the last years' research has focused on modulation of metabolic response and optimization of substrate utilization. The persisting variability of clinical practice is confirmed and results in difficult comparisons between burn centers.

RECENT FINDINGS

Recent research explores intracellular mechanisms of the massive metabolic turmoil observed after burns: very early alterations at the mitochondrial level largely explain the hypermetabolic response, with a diminished coupling of oxygen consumption and ATP production. The metabolic alterations (elevated protein and glucose turnover) have been shown to be long lasting. Modulating this response by pharmacological tools (insulin, propranolol, and oxandrolone) results in significant clinical benefits. A moderate glucose control proves to be safe in adult burns; data in children remain uncertain as the risk of hypoglycemia seems to be higher. The enteral feeding route is confirmed as an optimal route: some difficulties are now clearly identified, such as the risk of not delivering sufficient energy by this route.

SUMMARY

Major burn patients differ from other critically ill patients by the magnitude and duration of their inflammatory and metabolic responses, their energy and substrate requirements. Pieces of the metabolic puzzle finally seem to fit together.

A RandomizEd trial of ENtERal Glutamine to minimIZE thermal injury (The RE-ENERGIZE Trial): a clinical trial protocol

Background:

Burn injury represents a significant public health problem worldwide. More than in any other injury, the inflammation and catabolism associated with severe burns can exacerbate nutrient deficiencies resulting in impaired immune function and increased risk of developing infection, organ dysfunction and death. Consequently, over the last few decades numerous trials have evaluated the impact of different nutritional strategies in severe burn injury. Glutamine is of particular interest, as it appears vital for a number of key stress-response pathways in serious illness. The purpose of the current manuscript is to provide the rationale and protocol for a large clinical trial of supplemental enteral glutamine in 2700 severe burn-injured patients.

Methods:

We propose a multicentre, double-blind, pragmatic, randomized, clinical trial involving 80 tertiary intensive care unit (ICU) burn centres worldwide. We aim to enrol patients with deep second- and/or third-degree burns at moderate or high risk for death. We will exclude patients admitted > 72 h before screening and patients with advanced liver and kidney disease. The study intervention consists of enteral glutamine 0.5 g/kg/day vs. isocaloric maltodextran control delivered enterally. Primary outcome will be six-month mortality. Key secondary outcomes include time to discharge alive from hospital, ICU and hospital mortality, length of stay and health-related quality of life at six months.

Significance:

This study will be the first large international multicentre trial examining the effects of glutamine in burn patients. Negative or positive, the results of this trial will inform the clinical practice of burns care worldwide.

Clinicaltrials.gov ID #NCT00985205

Patients with severe burns need to recover in a hospital burn unit for a long time and are at high risk of developing infections and dying. Proper nutrition and certain nutrients may improve survival in these patients and shorten their stay in the burn unit. Glutamine is a building block of protein that is normally made in the body and is found in different foods we eat. It is of great interest because it has several beneficial effects on the body during serious illness, such as with burn injury. In this study, we will look at the effect of glutamine supplementation on survival and time spent in hospital. A total of 80 burn units around the world will enrol 2700 patients with 2nd or 3rd degree burns over 4 years. Patients will receive either glutamine powder or a placebo through a feeding tube or mixed with food, from admission to the burn unit, until a week after the burn wound has healed. The main outcome for this study is survival at 6 months. Other outcomes include the time taken to be discharged from hospital alive and duration of stay in the burn unit. This study will be the first large international multicentre trial examining the effects of glutamine in burn patients. Glutamine may lead to better survival and less complications in burn patients, who have a devastating and disabling burn injury. If the trial is positive, the results will be used to inform how nutrition should be given to such patients worldwide.

Update on metabolism and nutrition therapy in critically ill burn patients

Major burn injury triggers severe oxidative stress, a systemic inflammatory response, and a persistent hypermetabolic and hypercatabolic state with secondary sarcopenia, multiorgan dysfunction, sepsis and an increased mortality risk. Calorie deficit, negative protein balance and antioxidant micronutrient deficiency after thermal injury have been associated to poor clinical outcomes. In this context, personalized nutrition therapy with early enteral feeding from the start of resuscitation are indicated. Over the last four decades, different nutritional and pharmacological interventions aimed at modulating the immune and metabolic responses have been evaluated. These strategies have been shown to be able to minimize acute malnutrition, as well as modulate the immunoinflammatory response, and improve relevant clinical outcomes in this patient population. The purpose of this updating review is to summarize the most current evidence on metabolic response and nutrition therapy in critically ill burn patients.

Effectiveness of enteral feeding protocol on clinical outcomes in critically ill patients: a study protocol for before-and-after design

INTRODUCTION

Enteral feed is an important component of nutritional therapy in critically ill patients and underfeeding has been associated with adverse outcomes. The article developed an enteral feeding protocol and planed a before-and-after comparative trial to explore whether implementation of enteral feeding protocol was able to improve clinical outcomes.

METHODS AND ANALYSIS

The study will be conducted in intensive care units (ICUs) of ten tertiary care academic centers. Critically ill patients expected to stay in ICU for over 3 days and require enteral nutrition (EN) were potentially eligible. This is a before-and-after study comprising three phases: The first phase is the period without enteral feeding protocol; the second phase involves four-week training program, and the last phase is to perform the protocol in participating centers. We plan to enroll a total of 350 patients to provide an 80% power and 0.05 error rate to detect a 15% reduction of mortality. The primary outcome is 28-day mortality.

ETHICS AND DISSEMINATION

Ethical approval to conduct the research has been obtained from all participating centers. Additionally, the results will be published in peer-reviewed journal.

TRIAL REGISTRATION

The study was registered at International Standard Registered Clinical/soCial sTudy Number (ISRCTN) registry (ISRCTN10583582).

The effect of augmenting early nutritional energy delivery on quality of life and employment status one year after ICU admission

Augmenting energy delivery during the acute phase of critical illness may reduce mortality and improve functional outcomes. The objective of this sub-study was to evaluate the effect of early augmented enteral nutrition (EN) during critical illness, on outcomes one year later. We performed prospective longitudinal evaluation of study participants, initially enrolled in The Augmented versus Routine approach to Giving Energy Trial (TARGET), a feasibility study that randomised critically ill patients to 1.5 kcal/ml (augmented) or 1.0 kcal/ml (routine) EN administered at the same rate for up to ten days, who were alive at one year. One year after randomisation Short Form-36 version 2 (SF-36v2) and EuroQol-5D-5L quality of life surveys, and employment status were assessed via telephone survey. At one year there were 71 survivors (1.5 kcal/ml 38 versus 1.0 kcal/ml 33; P=0.55). Thirty-nine (55%) patients consented to this follow-up study and completed the surveys (n = 23 and 16, respectively). The SF-36v2 physical and mental component summary scores were below normal population means but were similar in 1.5 kcal/ml and 1.0 kcal/ml groups (P=0.90 and P=0.71). EuroQol-5D-5L data were also comparable between groups (P=0.70). However, at one-year follow-up, more patients who received 1.5 kcal/ml were employed (7 versus 2; P=0.022). The delivery of 1.5 kcal/ml for a maximum of ten days did not affect self-rated quality of life one year later.

Peri-operative nutrition

Patients are frequently malnourished or are at risk of malnutrition before surgery. Peri-operative nutritional support can improve their outcomes. This review focuses on new developments in peri-operative nutrition, including: patient preparation and pre-operative fasting; the role of nutritional supplementation; the optimal route and timing of nutrient delivery; and the nutritional management of specific groups including critically ill, obese and elderly patients.

Event-rate and delta inflation when evaluating mortality as a primary outcome from randomized controlled trials of nutritional interventions during critical illness: a systematic review

BACKGROUND

There is a lack of high-quality evidence that proves that nutritional interventions during critical illness reduce mortality.

OBJECTIVES

We evaluated whether power calculations for randomized controlled trials (RCTs) of nutritional interventions that used mortality as the primary outcome were realistic, and whether overestimation was systematic in the studies identified to determine whether this was due to overestimates of event rate or delta.

DESIGN

A systematic review of the literature between 2005 and 2015 was performed to identify RCTs of nutritional interventions administered to critically ill adults that had mortality as the primary outcome. Predicted event rate (predicted mortality during the control), predicted mortality during intervention, predicted delta (predicted difference between mortality during the control and intervention), actual event rate (observed mortality during control), observed mortality during intervention, and actual delta (difference between observed mortality during the control and intervention) were recorded. The event-rate gap (predicted event rate minus observed event rate), the delta gap (predicted delta minus observed delta), and the predicted number needed to treat were calculated. Data are shown as median (range).

RESULTS

Fourteen articles were extracted, with power calculations provided for 10 studies. The predicted event rate was 29.9% (20.0–52.4%), and the predicted delta was 7.9% (3.0–20.0%). If the study hypothesis was proven correct then, on the basis of the power calculations, the number needed to treat would have been 12.7 (5.0–33.3) patients. The actual event rate was 25.3% (6.1–50.0%), the observed mortality during the intervention was 24.4% (6.3–39.7%), and the actual delta was 0.5% (−10.2–10.3%), such that the event-rate gap was 2.6% (−3.9–23.7%) and delta gap was 7.5% (3.2–25.2%).

CONCLUSIONS

Overestimates of delta occur frequently in RCTs of nutritional interventions in the critically ill that are powered to determine a mortality benefit. Delta inflation may explain the number of "negative" studies in this field of research.

Nutrition support practices in critically ill head-injured patients: a global perspective

Background

Critical illness following head injury is associated with a hypermetabolic state but there are insufficient epidemiological data describing acute nutrition delivery to this group of patients. Furthermore, there is little information describing relationships between nutrition and clinical outcomes in this population.

Methods

We undertook an analysis of observational data, collected prospectively as part of International Nutrition Surveys 2007-2013, and extracted data obtained from critically ill patients with head trauma. Our objective was to describe global nutrition support practices in the first 12 days of hospital admission after head trauma, and to explore relationships between energy and protein intake and clinical outcomes. Data are presented as mean (SD), median (IQR), or percentages.

Results

Data for 1045 patients from 341 ICUs were analyzed. The age of patients was 44.5 (19.7) years, 78 % were male, and median ICU length of stay was 13.1 (IQR 7.9-21.6) days. Most patients (94 %) were enterally fed but received only 58 % of estimated energy and 53 % of estimated protein requirements. Patients from an ICU with a feeding protocol had greater energy and protein intakes (p <0.001, 0.002 respectively) and were more likely to survive (OR 0.65; 95 % CI 0.42-0.99; p = 0.043) than those without. Energy or protein intakes were not associated with mortality. However, a greater energy and protein deficit was associated with longer times until discharge alive from both ICU and hospital (all p <0.001).

Conclusion

Nutritional deficits are commonplace in critically ill head-injured patients and these deficits are associated with a delay to discharge alive.

Nutrition: A Primary Therapy in Pediatric Acute Respiratory Distress Syndrome

Appropriate nutrition is an essential component of intensive care management of children with acute respiratory distress syndrome (ARDS) and is linked to patient outcomes. One out of every two children in the pediatric intensive care unit (PICU) will develop malnutrition or have worsening of baseline malnutrition and present with specific micronutrient deficiencies. Early and adequate enteral nutrition (EN) is associated with improved 60-day survival after pediatric critical illness, and, yet, despite early EN guidelines, critically ill children receive on average only 55% of goal calories by PICU day 10. Inadequate delivery of EN is due to perceived feeding intolerance, reluctance to enterally feed children with hemodynamic instability, and fluid restriction. Underlying each of these factors is large practice variation between providers and across institutions for initiation, advancement, and maintenance of EN. Strategies to improve early initiation and advancement and to maintain delivery of EN are needed to improve morbidity and mortality from pediatric ARDS. Both, over and underfeeding, prolong duration of mechanical ventilation in children and worsen other organ function such that precise calorie goals are needed. The gut is thought to act as a "motor" of organ dysfunction, and emerging data regarding the role of intestinal barrier functions and the intestinal microbiome on organ dysfunction and outcomes of critical illness present exciting opportunities to improve patient outcomes. Nutrition should be considered a primary rather than supportive therapy for pediatric ARDS. Precise nutritional therapies, which are titrated and targeted to preservation of intestinal barrier function, prevention of intestinal dysbiosis, preservation of lean body mass, and blunting of the systemic inflammatory response, offer great potential for improving outcomes of pediatric ARDS. In this review, we examine the current evidence regarding dose, route, and timing of nutrition, current recommendations for provision of nutrition to children with ARDS, and the current literature for immune-modulating diets for pediatric ARDS. We will examine emerging data regarding the role of the intestinal microbiome in modulating the response to critical illness.