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Nunez JH, Clark AT. Burn Patient Metabolism and Nutrition. Phys Med Rehabil Clin N Am 2023; 34:717-731. [PMID: 37806693 DOI: 10.1016/j.pmr.2023.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/10/2023]
Abstract
Following severe burns, patients have unique metabolic derangements that make adequate nutritional support imperative for their survival and recovery. Patients with burns have persistent and prolonged hypermetabolic states that lead to increased catabolism following injury. During rehabilitation, catabolism leads to increased muscle wasting and cachexia. Failure to adequately meet the patient's increased nutritional requirements can lead to poor wound healing, increased infections, and overall organ dysfunction. Because of these risks, adequate assessment and provision of nutritional needs are imperative to care for these patients.
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Affiliation(s)
- Johanna H Nunez
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Audra T Clark
- Department of Surgery, University of Texas Southwestern Medical Center, E05514B, 5323 Harry Hines Boulevard, Dallas, TX 75390, USA.
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2
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Shahrokhi S, Jeschke MG. Metabolic and Nutritional Support. Surg Clin North Am 2023; 103:473-482. [PMID: 37149383 DOI: 10.1016/j.suc.2023.01.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/08/2023]
Abstract
Hypermetabolism is a hallmark of larger burn injuries. The hypermetabolic response is characterized by marked and sustained increases in catecholamines, glucocorticoids, and glucagon. There is an increasing body of literature for nutrition and metabolic treatment and supplementation to counter the hypermetabolic and catabolic response secondary to burn injury. Early and adequate nutrition is key in addition to adjunctive therapies, such as oxandrolone, insulin, metformin, and propranolol. The duration of administration of anabolic agents should be at minimum for the duration of hospitalization, and possibly up to 2 to 3 years postburn.
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Affiliation(s)
- Shahriar Shahrokhi
- Burn Program at Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Surgery, McMaster University, Hamilton, Ontario, Canada
| | - Marc G Jeschke
- Burn Program at Hamilton Health Sciences, Hamilton, Ontario, Canada; Department of Surgery, McMaster University, Hamilton, Ontario, Canada; TaAri Institute, Hamilton Health Sciences Research Institute, Hamilton, Ontario, Canada; David Braley Research Institute, C5-104, 237 Barton Street East, Hamilton, Ontario L8L 2X2, Canada.
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3
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Umbrello M, Marini JJ, Formenti P. Metabolic Support in Acute Respiratory Distress Syndrome: A Narrative Review. J Clin Med 2023; 12:jcm12093216. [PMID: 37176655 PMCID: PMC10179727 DOI: 10.3390/jcm12093216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Revised: 04/14/2023] [Accepted: 04/26/2023] [Indexed: 05/15/2023] Open
Abstract
Nutritional support for acute respiratory distress syndrome (ARDS) patients shares metabolic notions common to other critically ill conditions. Nevertheless, it generates specific concern regarding the primary limitation of oxygen supply and the complications of carbon dioxide elimination, as well as the significant metabolic alterations due to the body's response to illness. In the present narrative review, after briefly summarizing the pathophysiology of critical illness stress response and patients' metabolic requirements, we focus on describing the characteristics of metabolic and artificial nutrition in patients with acute respiratory failure. In patients with ARDS, several aspects of metabolism assume special importance. The physiological effects of substrate metabolism are described for this setting, particularly regarding energy consumption, diet-induced thermogenesis, and the price of their clearance, transformation, and storage. Moreover, we review the possible direct effects of macronutrients on lung tissue viability during ARDS. Finally, we summarize the noteworthy characteristics of metabolic control in critically ill patients with ARDS and offer a suggestion as to the ideal methods of metabolic support for this problem.
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Affiliation(s)
- Michele Umbrello
- Unità Operativa di Anestesia e Rianimazione II, Ospedaliera San Carlo, ASST Santi Paolo e Carlo, 20148 Milan, Italy
| | - John J Marini
- Department of Pulmonary and Critical Care Medicine, University of Minnesota, Minneapolis, MN 55455, USA
| | - Paolo Formenti
- SC Anestesia, Rianimazione e Terapia Intensiva, ASST Nord Milano, Ospedale Bassini, 20097 Cinisello Balsamo, Italy
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4
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Ren Y, Wang L, Zhan J, Liao W, Hu R, Luo J, Cheng X. An overview of current research on nutritional support for burn patients: a bibliometric analysis from 1983 to 2022. Nutrition 2023; 111:112027. [PMID: 37087943 DOI: 10.1016/j.nut.2023.112027] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2022] [Revised: 02/28/2023] [Accepted: 03/01/2023] [Indexed: 03/18/2023]
Abstract
OBJECTIVES Burn patients are reportedly prone to complications, such as skeletal muscle wasting, anemia, and slow wound healing, during treatment, due to disease and metabolic depletion, which affect prognosis. Nutritional support is essential in treating burns and can significantly improve patient survival and reduce complications such as infection. This study aimed to perform a bibliometric analysis of the existing literature on nutritional support for burns and to explore possible future research trends. METHODS The literature related to nutritional support for burns from 1983 to 2022 was searched on Web of Science. The included literature was used for bibliometric analysis using VOSviewer and CiteSpace software. RESULTS There were 260 publications on nutritional support for burns. The United States contributes significantly to research in this area. The United States has the highest number of publications (n = 119) and citations (n = 4424). Nutrition support was the keyword with strongest burst intensity. A diet of ≥ 60% carbohydrates and 12% to 15% fat is suitable for burn patients, but the optimal ratios have not been fully determined. CONCLUSIONS An optimal nutritional support program is essential for treating burn patients. Individualized nutritional support programs are the trend in this field. At present, more rigorous multicenter prospective studies with large samples are needed to explore the optimal ratios for specific dietary programs, especially macronutrients, to achieve satisfactory nutritional support and improve patient prognosis.
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Affiliation(s)
- Yujie Ren
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Lihui Wang
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Jianhua Zhan
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Wenqiang Liao
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Renchao Hu
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China
| | - Jinhua Luo
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China.
| | - Xing Cheng
- Medical Center of Burn Plastic and Wound Repair, The First Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, People's Republic of China.
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5
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Muacevic A, Adler JR, Torres R, Maita K, Garcia J, Serrano L, Ho O, Forte AJ. Modulation of Burn Hypermetabolism in Preclinical Models. Cureus 2023; 15:e33518. [PMID: 36779088 PMCID: PMC9904913 DOI: 10.7759/cureus.33518] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/08/2023] [Indexed: 01/11/2023] Open
Abstract
Severe burns elicit a state of physiological stress and increased metabolism to help the body compensate for the changes associated with the traumatic injury. However, this hypermetabolic state is associated with increased insulin resistance, cardiovascular dysfunction, skeletal muscle catabolism, impaired wound healing, and delayed recovery. Several interventions were attempted to modulate burn hypermetabolism, including nutritional support, early excision and grafting, and growth hormone application. However, burn hypermetabolism still imposes significant morbidity and mortality in burn patients. Due to the limitations of in vitro models, animal models are indispensable in burn research. Animal models provide researchers with invaluable tools to test the safety and efficacy of novel treatments or advance our knowledge of previously utilized agents. Several animal studies evaluated novel therapies to modulate burn hypermetabolism in the last few years, including recombinant human growth hormone, erythropoietin, acipimox, apelin, anti-interleukin-6 monoclonal antibody, and ghrelin therapies. Results from these studies are promising and may be effectively translated into human studies. In addition, other studies revisited drugs previously used in clinical practice, such as insulin and metformin, to further investigate their underlying mechanisms as modulators of burn hypermetabolism. This review aims to update burn experts with the novel therapies under investigation in burn hypermetabolism with a focus on applicability and translation. Furthermore, we aim to guide researchers in selecting the correct animal model for their experiments by providing a summary of the methodology and the rationale of the latest studies.
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Effects of Different Ratios of Carbohydrate-Fat in Enteral Nutrition on Metabolic Pattern and Organ Damage in Burned Rats. Nutrients 2022; 14:nu14173653. [PMID: 36079913 PMCID: PMC9460118 DOI: 10.3390/nu14173653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2022] [Revised: 08/31/2022] [Accepted: 09/01/2022] [Indexed: 11/21/2022] Open
Abstract
(1) Background: Nutritional support is one of the most important cornerstones in the management of patients with severe burns, but the carbohydrate-to-fat ratios in burn nutrition therapy remain highly controversial. In this study, we aimed to discuss the effects of different ratios of carbohydrate–fat through enteral nutrition on the metabolic changes and organ damage in burned rats. (2) Methods: Twenty-four burned rats were randomly divided into 5%, 10%, 20% and 30% fat nutritional groups. REE and body weight were measured individually for each rat daily. Then, 75% of REE was given in the first week after burns, and the full dose was given in the second week. Glucose tolerance of the rats was measured on days 1, 3, 7, 10 and 14. Blood biochemistry analysis and organ damage analysis were performed after 7 and 14 days of nutritional therapy, and nuclear magnetic resonance (NMR) and insulin content analysis were performed after 14 days. (3) Results: NMR spectra showed significant differences of glucose, lipid and amino acid metabolic pathways. The energy expenditure increased, and body weight decreased significantly after burn injury, with larger change in the 20%, 5% and 30% fat groups, and minimal change in the 10% fat group. The obvious changes in the level of plasma protein, glucose, lipids and insulin, as well as the organ damage, were in the 30%, 20% and 5% fat groups. In relative terms, the 10% fat group showed the least variation and was closest to normal group. (4) Conclusion: Lower fat intake is beneficial to maintaining metabolic stability and lessening organ damage after burns, but percentage of fat supply should not be less than 10% in burned rats.
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7
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Santos HO, Genario R, Tinsley GM, Ribeiro P, Carteri RB, Coelho-Ravagnani CDF, Mota JF. A scoping review of intermittent fasting, chronobiology, and metabolism. Am J Clin Nutr 2022; 115:991-1004. [PMID: 34978321 DOI: 10.1093/ajcn/nqab433] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 12/29/2021] [Indexed: 12/19/2022] Open
Abstract
Chronobiology plays a crucial role in modulating many physiologic systems in which there is nutritional synergism with meal timing. Given that intermittent fasting (IF) has grown as a flexible dietary method consisting of delayed or early eating windows, this scoping review addresses the effects of IF protocols on metabolism as they relate to clinical nutrition and the circadian system. Although nocturnal habits are associated with circadian misalignments and impaired cardiometabolic profile-and nutritional physiology is better orchestrated during the day-most findings are based on animal experiments or human studies with observational designs or acute meal tests. Well-controlled randomized clinical trials employing IF protocols of delayed or early eating windows have sometimes demonstrated clinical benefits, such as improved glycemic and lipid profiles, as well as weight loss. However, IF does not appear to be more effective than traditional diets at the group level, and its effects largely depend on energy restriction. Thus, efforts must be made to identify patient biological rhythms, preferences, routines, and medical conditions before individual dietary prescription in clinical practice.
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Affiliation(s)
- Heitor O Santos
- School of Medicine, Federal University of Uberlandia (UFU), Uberlandia, Minas Gerais, Brazil
| | - Rafael Genario
- School of Medicine, University of São Paulo (USP), São Paulo, Brazil
| | - Grant M Tinsley
- Department of Kinesiology & Sport Management, Texas Tech University, Lubbock, TX, USA
| | - Poliana Ribeiro
- Institute of Genetics and Biochemistry, Federal University of Uberlandia (UFU), Uberlandia, Minas Gerais, Brazil
| | - Randhall B Carteri
- Methodist University Center-Porto Alegre Institute, Porto Alegre, Brazil
| | | | - João F Mota
- Clinical and Sports Nutrition Research Laboratory, Faculty of Nutrition, Goiás Federal University, Goiânia, GO, Brazil
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8
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Abstract
ABSTRACT Management of the metabolic responses to severe burn injury is recognized as a fundamental part of burn care. Definition of burn hypermetabolism is being refined to subcellular and genomic levels, and treatment concepts are need to be refined into increasingly sophisticated strategies.
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Affiliation(s)
- David Herndon
- From the Joseph M. Still Research Foundation, Inc., Augusta, GA
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9
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Smith-Ryan AE, Hirsch KR, Saylor HE, Gould LM, Blue MNM. Nutritional Considerations and Strategies to Facilitate Injury Recovery and Rehabilitation. J Athl Train 2021; 55:918-930. [PMID: 32991705 DOI: 10.4085/1062-6050-550-19] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
Nutritional interventions are not commonly a standard of care in rehabilitation interventions. A nutritional approach has the potential to be a low-cost, high-volume strategy that complements the existing standard of care. In this commentary, our aim is to provide an evidence-based, practical guide for athletes with injuries treated surgically or conservatively, along with healing and rehabilitation considerations. Injuries are a normal and expected part of exercise participation. Regardless of severity, an injury typically results in the athlete's short- or long-term removal from participation. Nutritional interventions may augment the recovery process and support optimal healing; therefore, incorporating nutritional strategies is important at each stage of the healing process. Preoperative nutrition and nutritional demands during rehabilitation are key factors to consider. The physiological response to wounds, immobilization, and traumatic brain injuries may be improved by optimizing macronutrient composition, caloric consumption, and nutrient timing and using select dietary supplements. Previous research supports practical nutrition recommendations to reduce surgical complications, minimize deficits after immobilization, and maximize the chance of safe return to play. These recommendations include identifying the individual's caloric requirements to ensure that energy needs are being met. A higher protein intake, with special attention to evenly distributed consumption throughout the day, will help to minimize loss of muscle and strength during immobilization. Dietary-supplement strategies may be useful when navigating the challenges of appropriate caloric intake and timing and a reduced appetite. The rehabilitation process also requires a strong nutritional plan to enhance recovery from injury. Athletic trainers, physical therapists, and other health care professionals should provide basic nutritional recommendations during rehabilitation, discuss the timing of meals with respect to therapy, and refer the patient to a registered dietitian if warranted. Because nutrition plays an essential role in injury recovery and rehabilitation, nutritional interventions should become a component of standard-of-care practice after injury. In this article, we address best practices for implementing nutritional strategies among patients with athletic injuries.
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Affiliation(s)
- Abbie E Smith-Ryan
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill.,Human Movement Science Curriculum, University of North Carolina at Chapel Hill.,Department of Nutrition, Gillings School of Public Health, University of North Carolina at Chapel Hill
| | - Katie R Hirsch
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill.,Human Movement Science Curriculum, University of North Carolina at Chapel Hill
| | - Hannah E Saylor
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill.,Human Movement Science Curriculum, University of North Carolina at Chapel Hill
| | - Lacey M Gould
- Department of Exercise and Sport Science, University of North Carolina at Chapel Hill
| | - Malia N M Blue
- Human Movement Science Curriculum, University of North Carolina at Chapel Hill
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10
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Geometric framework reveals that a moderate protein, high carbohydrate intake is optimal for severe burn injury in mice. Br J Nutr 2020; 123:1056-1067. [PMID: 31983360 DOI: 10.1017/s0007114520000276] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
Nutritional therapy is a cornerstone of burns management. The optimal macronutrient intake for wound healing after burn injury has not been identified, although high-energy, high-protein diets are favoured. The present study aimed to identify the optimal macronutrient intake for burn wound healing. The geometric framework (GF) was used to analyse wound healing after a 10 % total body surface area contact burn in mice ad libitum fed one of the eleven high-energy diets, varying in macronutrient composition with protein (P5-60 %), carbohydrate (C20-75 %) and fat (F20-75 %). In the GF study, the optimal ratio for wound healing was identified as a moderate-protein, high-carbohydrate diet with a protein:carbohydrate:fat (P:C:F) ratio of 1:4:2. High carbohydrate intake was associated with lower mortality, improved body weight and a beneficial pattern of body fat reserves. Protein intake was essential to prevent weight loss and mortality, but a protein intake target of about 7 kJ/d (about 15 % of energy intake) was identified, above which no further benefit was gained. High protein intake was associated with delayed wound healing and increased liver and spleen weight. As the GF study demonstrated that an initial very high protein intake prevented mortality, a very high-protein, moderate-carbohydrate diet (P40:C42:F18) was specifically designed. The dynamic diet study was also designed to combine and validate the benefits of an initial very high protein intake for mortality, and subsequent moderate protein, high carbohydrate intake for optimal wound healing. The dynamic feeding experiment showed switching from an initial very high-protein diet to the optimal moderate-protein, high-carbohydrate diet accelerated wound healing whilst preventing mortality and liver enlargement.
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11
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Polychronopoulou E, Herndon DN, Porter C. The Long-Term Impact of Severe Burn Trauma on Musculoskeletal Health. J Burn Care Res 2020; 39:869-880. [PMID: 30010999 DOI: 10.1093/jbcr/iry035] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 06/15/2018] [Indexed: 12/13/2022]
Abstract
Severe burn injury causes a profound stress response that leads to muscle and bone cachexia. Evidence suggests that these deficits persist for several months or even years after injury and are associated with growth delay, increased incidence of fractures, and increased hospital admissions for musculoskeletal disorders. Thus, there is an overwhelming need to determine the optimal acute and rehabilitative strategies to mitigate these deficits and improve quality of life for burn survivors. To date, there is limited research on the long-term impact of cachexia on functional performance and overall health, as well as on the lasting impact of pharmacological, nutritional, and exercise interventions. The aim of this review is to emphasize the long-term consequences of musculoskeletal cachexia and determine the best evidence-based strategies to attenuate it. We also underline important knowledge gaps that need to be addressed in order to improve care of burn survivors.
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Affiliation(s)
- Efstathia Polychronopoulou
- Division of Rehabilitation Sciences, University of Texas Medical Branch, Galveston, Texas.,Shriners Hospitals for Children - Galveston, Galveston, Texas
| | - David N Herndon
- Shriners Hospitals for Children - Galveston, Galveston, Texas.,Department of Surgery, University of Texas Medical Branch, Galveston, Texas
| | - Craig Porter
- Shriners Hospitals for Children - Galveston, Galveston, Texas.,Department of Surgery, University of Texas Medical Branch, Galveston, Texas
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12
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Rivas E, Herndon DN, Cambiaso-Daniel J, Rontoyanni VG, Porter C, Glover S, Suman OE. Quantification of an Exercise Rehabilitation Program for Severely Burned Children: The Standard of Care at Shriners Hospitals for Children®-Galveston. J Burn Care Res 2020; 39:889-896. [PMID: 29596648 DOI: 10.1093/jbcr/iry001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Currently, there are no clear guidelines for the implementation of rehabilitative exercise training (RET) in burned individuals. Therefore, we quantified the training logs for exercise intensity, frequency, and duration of 6 weeks of this program to develop a basic framework for outpatient RET in patients recovering from severe burns. Thirty-three children (11 female, [mean ± SD] 12 ± 3 years, 145 ± 18 cm, 40 ± 11 kg, 49 ± 31 BMI percentile) with severe burns (49 ± 15% total body surface area burned, with 35 ± 22% third-degree burns) completed our 6-week resistance and aerobic exercise training program. Cardiorespiratory fitness (peak VO2), strength, power, and lean body mass (LBM) were measured before and after RET. Outcome measures were analyzed as a relative percentage of values in age- and sex-matched nonburned children (11 female, 12 ± 3 years, 154 ± 20 cm, 49 ± 22 kg, 56 ± 25 BMI percentile). At discharge, burned children had lower LBM (77% of age-sex-matched nonburn values), peak torque (53%), power (62%), and cardiorespiratory fitness (56%). After 6 weeks of training, LBM increased by 5% (82% of nonburn values), peak torque by 18% (71%), power by 20% (81%), and cardiorespiratory fitness by 18% (74%; P < .0001 for all). Quantification of data in exercise training logs suggested that physical capacity can be improved by aerobic exercise training performed at five metabolic equivalents (>70% of peak VO2) at least 3 days/week and 150 minutes/week and by resistance training performed at volume loads (reps × sets × weight) of 131 kg for the upper body and 275 kg for the lower body for 2 days/week. We present for the first time the quantification of our RET and provide clear exercise prescription guidelines specific to children with severe burn injury.
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Affiliation(s)
- Eric Rivas
- Department of Surgery, Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas.,Department of Kinesiology and Sport Management, Texas Tech University, Lubbock, Texas
| | - David N Herndon
- Department of Surgery, Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas
| | - Janos Cambiaso-Daniel
- Department of Surgery, Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas.,Department of Surgery, Division of Plastic, Aesthetic and Reconstructive Surgery, Medical University of Graz, Austria
| | - Victoria G Rontoyanni
- Department of Surgery, Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas
| | - Craig Porter
- Department of Surgery, Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas
| | - Shauna Glover
- Department of Surgery, Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas
| | - Oscar E Suman
- Department of Surgery, Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas
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13
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Clayton RP, Herndon DN, Abate N, Porter C. The Effect of Burn Trauma on Lipid and Glucose Metabolism: Implications for Insulin Sensitivity. J Burn Care Res 2020; 39:713-723. [PMID: 29931151 DOI: 10.1093/jbcr/irx047] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
Severe burns represent a unique form of trauma in terms of the magnitude and persistence of the stress response they incur. Given advances in acute burn care in the last quarter of a century and the resultant reduction in mortality rates, even for those with massive burns, greater emphasis is now placed on understanding the metabolic stress response to severe burn trauma in order to devise strategies that promote recovery and reduce morbidity. Derangements in metabolism including protein and lipid redistribution and altered glucose handling are hallmarks of the pathophysiological response to burn trauma. In this review article, we aim to distill and discuss the c urrent literature concerning the effect of burn trauma on lipid and glucose metabolism. Furthermore, we will discuss the implications of altered lipid metabolism with regards to insulin sensitivity and glucose control, while discussing the utility of agents and strategies aimed at restoring normal lipid and glucose metabolism in burned patients.
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Affiliation(s)
- Robert P Clayton
- Shriners Hospitals for Children®-Galveston.,The Institute for Translational Sciences, University of Texas Medical Branch, Galveston
| | - David N Herndon
- Shriners Hospitals for Children®-Galveston.,The Institute for Translational Sciences, University of Texas Medical Branch, Galveston.,Department of Surgery, University of Texas Medical Branch, Galveston
| | - Nicola Abate
- Shriners Hospitals for Children®-Galveston.,The Institute for Translational Sciences, University of Texas Medical Branch, Galveston.,Department of Internal Medicine, University of Texas Medical Branch, Galveston
| | - Craig Porter
- Shriners Hospitals for Children®-Galveston.,The Institute for Translational Sciences, University of Texas Medical Branch, Galveston
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14
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Resting β-Adrenergic Blockade Does Not Alter Exercise Thermoregulation in Children With Burn Injury: A Randomized Control Trial. J Burn Care Res 2019; 39:402-412. [PMID: 28661984 DOI: 10.1097/bcr.0000000000000610] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
The objective of this study was to test the hypothesis that propranolol, a commonly prescribed β-blocker to burned children, in combination with exercise-heat stress, increases the risk of heat illness and exercise intolerance. In a randomized double-blind study, propranolol was given to 10 burned children, and placebo was given to 10 additional burned children (matched for TBSA burned; mean ± SD, 62 ± 13%), while nonburned children served as healthy controls. All groups were matched for age and body morphology (11.2 ± 3.0 years; 146 ± 19 cm; 45 ± 18 kg; 1.3 ± 0.4 m2). All children exercised in hot conditions (34.3 ± 1.0°C; 26 ± 2% relative humidity) at 75% of their peak aerobic capacity. At the end of exercise, none of the groups differed for final or change from baseline intestinal temperature (38.0 ± 0.5°C; 0.02 ± 0.01Δ°C·min-1), unburned (37.0 ± 0.6°C) and burned skin temperatures (36.9 ± 0.7°C; nonburn group excluded), heat loss (21 ± 18 W m-2), whole-body thermal conductance (118 ± 113 W m-2), or physiological strain index (5.6 ± 1). However, burn children exercised less than nonburn group (21.2 ± 8.6 vs 30 ± 0.0 min; P < .001) and had a lower calculated exercise tolerance index (1.0 ± 0.0 vs 6.7 ± 4.3; P < .01). Burned children had lower peak heart rates than nonburned children (173 ± 13 vs 189 ± 7 bpm; P < .01), with greater relative cardiac work rates at the end of exercise (97 ± 10 vs 85 ± 11% peak heart rate; P < .01). Resting β-adrenergic blockade does not affect internal body temperature of burned children exercising at similar relative intensities as nonburn children in the heat. Independent of propranolol, a suppressed cardiac function may be associated to exercise intolerance in children with severe burn injury.
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15
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Sommerhalder C, Blears E, Murton AJ, Porter C, Finnerty C, Herndon DN. Current problems in burn hypermetabolism. Curr Probl Surg 2019; 57:100709. [PMID: 32033707 DOI: 10.1016/j.cpsurg.2019.100709] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/08/2019] [Indexed: 12/29/2022]
Affiliation(s)
| | | | | | - Craig Porter
- Department of Pediatrics, University of Arkansas for Medical Sciences, Little Rock, AR
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16
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Guo Y, You Y, Lv D, Yan J, Shang FF, Wang X, Zhang C, Fan Q, Luo S. Inducible nitric oxide synthase contributes to insulin resistance and cardiac dysfunction after burn injury in mice. Life Sci 2019; 239:116912. [PMID: 31634465 DOI: 10.1016/j.lfs.2019.116912] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2019] [Revised: 09/12/2019] [Accepted: 09/24/2019] [Indexed: 11/18/2022]
Abstract
AIMS Cardiac dysfunction is a major cause of multi-organ dysfunction in critical care units following severe burns. The purpose of this study was to investigate the role of inducible nitric oxide synthase (iNOS) in cardiac dysfunction in burned mice. MATERIALS AND METHODS Wild-type and iNOS-knockout mice were subjected to 30% total body surface area burns. Next, the expression of iNOS was measured at 1, 3 and 7 days post-burn. Cardiac function, insulin sensitivity, inflammation, oxidative stress, and apoptosis in the hearts of the mice were assessed at 3 days post-burn. KEY FINDINGS Compared to control mice, iNOS expression was increased and reached a maximum in the heart of burned mice at 3 days post-burn. iNOS deficiency significantly alleviated the cardiac dysfunction and insulin resistance in burned mice. In addition, burn-induced inflammation, oxidative stress, and apoptosis in the heart were markedly reduced in iNOS-knockout burned mice when compared to corresponding values in wild-type burned mice. SIGNIFICANCE Our study demonstrates that iNOS contributes to insulin resistance in the hearts of mice following burn injury, and iNOS deficiency protects cardiac function against burn injury in mice, suggesting iNOS as a potential therapeutic target to treat burn injuries.
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Affiliation(s)
- Yongzheng Guo
- Division of cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing, 400016, China
| | - Yuehua You
- Division of cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing, 400016, China
| | - Dingyi Lv
- Division of cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China; Institute of Life Science, Chongqing Medical University, Chongqing, 400016, China
| | - Jianghong Yan
- Institute of Life Science, Chongqing Medical University, Chongqing, 400016, China
| | - Fei-Fei Shang
- Institute of Life Science, Chongqing Medical University, Chongqing, 400016, China
| | - Xiaowen Wang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Cheng Zhang
- Department of Cardiothoracic Surgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Qingdan Fan
- Division of cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China
| | - Suxin Luo
- Division of cardiology, The First Affiliated Hospital of Chongqing Medical University, Chongqing, 400016, China.
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The Role of Mitochondrial Stress in Muscle Wasting Following Severe Burn Trauma. J Burn Care Res 2019; 39:100-108. [PMID: 28448295 DOI: 10.1097/bcr.0000000000000553] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/26/2018] [Indexed: 11/26/2022]
Abstract
Increased resting metabolic rate and skeletal muscle wasting are hallmarks of the pathophysiological stress response to severe burn trauma. However, whether these two responses occur independently in burn patients or are in fact related remains unclear. In light of recent evidence demonstrating that increased proteolysis in skeletal muscle of burned patients is accompanied by mitochondrial hypermetabolism, oxidative stress, and protein damage; in this article, we discuss the evidence for a role for the mitochondrion in skeletal muscle wasting following severe burn trauma. In particular, we focus on the role of mitochondrial superoxide production in oxidative stress and subsequent proteolysis, and discuss the role of the mitochondrion as a signaling organelle resulting in protein catabolism in other cellular compartments following severe burn trauma.
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Shields BA, VanFosson CA, Pruskowski KA, Gurney JM, Rizzo JA, Cancio LC. High-Carbohydrate vs High-Fat Nutrition for Burn Patients. Nutr Clin Pract 2019; 34:688-694. [PMID: 31441112 DOI: 10.1002/ncp.10396] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Nutrition is an essential component of the healing and recovery process after severe burn injury. For many burn patients, nutrition support is necessary to meet nutrition goals. The ratio of carbohydrates and fat is particularly important for burn patients, as an essential fatty acid deficiency can contribute to poor wound healing. However, there is evidence to suggest that diets containing more carbohydrates and less fat may result in better patient outcomes. A literature search was conducted to identify studies related to nutrition support and macronutrient ratios in burn patients. Eleven published papers were found that considered macronutrient use in enteral and parenteral nutrition therapies among 9 different burn patient samples. No negative outcomes associated with lower fat, higher carbohydrate nutrition for severely burned patients were found in the literature. Conversely, the literature review revealed improved outcomes among severely burned patients receiving lower fat, higher carbohydrate nutrition to include fewer incidences of pneumonia, wound infections, acute respiratory distress syndrome, fatty liver, and sepsis. These patients also experienced shorter hospital length of stay and shorter wound healing times, as well as lower spleen and kidney weights, lower urinary nitrogen losses, improved nitrogen balance, higher insulin levels, higher insulin-like growth factor-1, lower cortisol, and less muscle protein breakdown. The evidence available to date supports the clinical use of nutrition support providing ≤15% fat and ≥60% carbohydrate for critically ill burn patients.
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Affiliation(s)
- Beth A Shields
- United States Army Institute of Surgical Research, Joint Base San Antonio, Texas, USA
| | | | - Kaitlin A Pruskowski
- United States Army Institute of Surgical Research, Joint Base San Antonio, Texas, USA
| | - Jennifer M Gurney
- United States Army Institute of Surgical Research, Joint Base San Antonio, Texas, USA
| | - Julie A Rizzo
- United States Army Institute of Surgical Research, Joint Base San Antonio, Texas, USA
| | - Leopoldo C Cancio
- United States Army Institute of Surgical Research, Joint Base San Antonio, Texas, USA
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Daemi A, Farahpour MR, Oryan A, Karimzadeh S, Tajer E. Topical administration of hydroethanolic extract of Lawsonia inermis (henna) accelerates excisional wound healing process by reducing tissue inflammation and amplifying glucose uptake. Kaohsiung J Med Sci 2019; 35:24-32. [PMID: 30844141 DOI: 10.1002/kjm2.12005] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 11/22/2018] [Indexed: 12/13/2022] Open
Abstract
Several studies have reported the beneficial effects of Lawsonia inermis on wound healing, but the mechanism of action is still unknown. This study aimed to investigate the effectiveness of a new ointment formulation of hydroethanolic extract leaves of L. inermis on wound healing by gene expression of glucose transporter-1 (Glut-1) and insulin-like growth factor I (Igf-1) in Wistar rats. The animals were topically treated with different doses of L. inermis. An experimentally induced circular excisional wound model of 314 mm2 surface area was surgically created. The percentage of wound contraction and histopathological changes was assessed at different time points following wound induction. The expression of Glut-1 and Igf-1 was evaluated by reverse-transcription PCR. Topical administration of L. inermis, dose dependently, shortened inflammatory phase, accelerated cellular proliferation, and enhanced wound contraction ratio. It also improved revascularization, collagen deposition, and re-epithelialization rate and promoted intracytoplasmic carbohydrate storage (P < 0.05). Moreover, the mRNA levels of Igf-1 and Glut-1 were significantly higher in the L. inermis-treated groups than the control group (P < 0.05). Topical administration of L. inermis promoted the healing process by reducing tissue inflammation and increasing glucose uptake, which was mediated by up-regulating the expression of Igf-1 and Glut-1.
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Affiliation(s)
- Amin Daemi
- Department of Biology, Miandoab Branch, Islamic Azad University, Miandoab, Iran
| | - Mohammad R Farahpour
- Young Researchers and Elite Club, Urmia Branch, Islamic Azad University, Urmia, Iran
| | - Ahmad Oryan
- Department of Pathology, School of Veterinary Medicine, Shiraz University, Shiraz, Iran
| | - Sirvan Karimzadeh
- Faculty of Veterinary Medicine, Urmia Branch, Islamic Azad University, Urmia, Iran
| | - Ehsan Tajer
- Faculty of Veterinary Medicine, Urmia Branch, Islamic Azad University, Urmia, Iran
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20
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Determinants of skeletal muscle protein turnover following severe burn trauma in children. Clin Nutr 2018; 38:1348-1354. [PMID: 29907353 DOI: 10.1016/j.clnu.2018.05.027] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 02/17/2018] [Accepted: 05/29/2018] [Indexed: 12/20/2022]
Abstract
BACKGROUND & AIMS Burns remain the fifth cause of non-fatal pediatric injuries globally, with muscle cachexia being a hallmark of the stress response to burns. Burn-induced muscle wasting is associated with morbidity, yet the determinants of muscle protein catabolism in response to burn trauma remains unclear. Our objective was to determine the effect of patient and injury characteristics on muscle protein kinetics in burn patients. METHODS This retrospective, observational study was performed using protein kinetic data from pediatric patients who had severe burns (>30% of the total body surface area burned) and underwent cross-limb stable isotope infusions between 1999 and 2008 as part of prospective clinical trials. Mixed multiple regression models were used to assess associations between patient/injury characteristics and muscle protein fractional synthesis rate (FSR), net balance (NB), and rates of phenylalanine appearance (Ra; index of protein breakdown) and disappearance (Rd; index of protein synthesis) across the leg. RESULTS A total of 268 patients who underwent 499 studies were analyzed. Increasing time post injury was associated with greater FSR (p < 0.001) and NB (p = 0.01). Males were more catabolic than females (as indicated by lower NB, p = 0.04 and greater Ra, p = 0.008), a consequence of higher protein breakdown rather than lower synthesis. Increasing burn size was associated with higher protein synthesis rate (as indicated by higher FSR, p = 0.019) and higher protein breakdown rates (as indicated by greater Ra, p = 0.001). FSR was negatively associated with age (p < 0.001). CONCLUSIONS Data from this large patient cohort show that injury severity, sex, and time post injury influence skeletal muscle wasting in burned children. These findings suggest that individual patient characteristics should be considered when devising therapies to improve the acute care and rehabilitation of burn survivors.
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Abstract
PURPOSE OF REVIEW A complex network of hormones and other effectors characterize the hypermetabolic response in critical illness; these mediators work together to induce numerous pathophysiologic alterations. Increased incidence of infection, multiorgan failure, long-term debilitation, delays in rehabilitation, and death result from an inability to meet the prohibitively elevated protein and energy requirements, which occur during illness and can persist for several years. Pharmacologic interventions have been successfully utilized to attenuate particular aspects of the hypermetabolic response; these modalities are a component of managing critically ill patients - including those patients with severe burns. Here, we review recent advances in pharmacologically attenuating the hypermetabolic and catabolic responses. RECENT FINDINGS Propranolol, a nonspecific β-adrenergic receptor antagonist, is one of the most widely used anticatabolic therapies. Oxandrolone, testosterone, and intensive insulin therapy represent anabolic pharmacological strategies. Promising therapies, such as metformin, glucagon-like peptide 1, peroxisome proliferator-activated receptor agonists, are currently being investigated. SUMMARY Profound metabolic derangements occur in critically ill patients; this hypermetabolic response is a major contributor to adverse outcomes. Despite the pharmacological therapies currently available to counteract this devastating cascade, future studies are warranted to explore new multimodality agents that will counteract these effects while maintaining glycemic control and preventing unfavorable complications.
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22
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Rivas E, Herndon DN, Porter C, Meyer W, Suman OE. Short-term metformin and exercise training effects on strength, aerobic capacity, glycemic control, and mitochondrial function in children with burn injury. Am J Physiol Endocrinol Metab 2018; 314:E232-E240. [PMID: 29138224 PMCID: PMC5899215 DOI: 10.1152/ajpendo.00194.2017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Severely burned children experience a chronic state of sympathetic nervous system activation that is associated with hypermetabolic/cardiac stress and muscle wasting. Metformin, a diabetes medication, helps control hyperglycemia in obese diabetic populations, and exercise has been shown to improve exercise strength and aerobic exercise capacity after severe burns. However, whether exercise improves glycemic control in burned children and whether combining exercise and metformin improves outcomes to a greater degree than exercise alone are unknown. We tested the hypothesis that a 6-wk exercise program combined with short-term metformin administration (E + M) improves aerobic and strength exercise capacity to a greater degree than exercise and placebo (E), while improving glucose tolerance and muscle metabolic function. We found that, before exercise training, the metformin group compared with the placebo group had attenuated mitochondrial respiration (pmol·s-1·mg-1) for each state: state 2 (-22.5 ± 3), state 3 (-42.4 ± 13), and oxphos (-58.9 ± 19) ( P ≤ 0.02, M vs. E + M group for each state). However, in the E + M group, exercise increased mitochondrial respiration in each state ( P ≤ 0.05), with respiration being comparable to that in the E group (each P > 0.05). In both groups, exercise induced comparable improvements in strength (change from preexercise, Δ1.6 ± 0.6 N-M·kgLBM) and V̇o2peak (Δ9 ± 7 mlO2·kgLBM) as well as fasting glucose (Δ19.3 ± 13 mg·dl) and glucose AUC (Δ3402 ± 3674 mg·dl-1·min-1), as measured by a 75-g OGTT (all P ≤ 0.03). Exercise reduced resting energy expenditure in E + M (Δ539 ± 480 kcal/24 h, P < 0.01) but not E subjects ( P = 0.68). Both groups exhibited reduced resting heart rate (Δ30 ± 23 beats/min, P ≤ 0.02). These data indicate that short-term metformin combined with exercise provides no further improvement beyond that of exercise alone for strength, exercise capacity, and glycemic control.
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Affiliation(s)
- Eric Rivas
- Shriners Hospitals for Children, Galveston, Texas
- Department of Surgery, University of Texas Medical Branch , Galveston, Texas
- Department of Kinesiology and Sport Management, Texas Tech University , Lubbock, Texas
| | - David N Herndon
- Shriners Hospitals for Children, Galveston, Texas
- Department of Surgery, University of Texas Medical Branch , Galveston, Texas
| | - Craig Porter
- Shriners Hospitals for Children, Galveston, Texas
- Department of Surgery, University of Texas Medical Branch , Galveston, Texas
| | - Walter Meyer
- Shriners Hospitals for Children, Galveston, Texas
- Department of Surgery, University of Texas Medical Branch , Galveston, Texas
| | - Oscar E Suman
- Shriners Hospitals for Children, Galveston, Texas
- Department of Surgery, University of Texas Medical Branch , Galveston, Texas
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23
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Charrière M, Ridley E, Hastings J, Bianchet O, Scheinkestel C, Berger MM. Propofol sedation substantially increases the caloric and lipid intake in critically ill patients. Nutrition 2017; 42:64-68. [PMID: 28870480 DOI: 10.1016/j.nut.2017.05.009] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2017] [Revised: 04/11/2017] [Accepted: 05/15/2017] [Indexed: 10/19/2022]
Abstract
OBJECTIVE The amount of lipid delivered to patients varies considerably depending on the non-nutritional intake from sedation, and on the feeding solution. The aim of this study was to quantify the magnitude and proportion of lipids and energy provided from propofol sedation in intensive care unit (ICU) patients. METHODS This was a retrospective analysis of prospectively collected data in consecutive patients admitted to the ICUs of two university hospitals. Inclusion criterion included an ICU stay >5 d. Data were collected for a maximum of 10 d. Propofol sedation using 1% or 2% propofol solutions was defined as >100 mg/d. Nutritional management was per protocol in both centers, recommending enteral feeding. Data are shown as means ± standard deviation. RESULTS In all, 701 admissions (687 patients, ages 59 ± 16 y, SAPS II 51 ± 17) and 6485 d, including 3484 propofol sedation days were analyzed. Energy targets were 1987 ± 411 kcal/d; mean energy delivery was 1362 ± 811 kcal/d (70% ± 38% of prescription) including propofol and dextrose. Enteral feeding dominated (75% of days) and progressed similarly in both ICUs. Mean propofol sedation dose was 2045 ± 1650 mg/d, resulting in 146 ± 117 kcal/d. Fat from propofol constituted 17% of total energy (up to 100% during the first days). Fat delivery (40 ± 23 g/d: maximum 310 g/d) was significantly increased by the combination of propofol sedation, the 1% solution, and high-fat-containing feeds. In survivors, high-fat proportion was associated with prolonged ventilation time (P < 0.0001). CONCLUSION Propofol sedation resulted in large doses of lipids being delivered to patients, some receiving pure lipids during the first days. As the metabolic effects of high proportions of fat are unknown, further research is warranted.
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Affiliation(s)
- Mélanie Charrière
- Service of Intensive Care Medicine, University Hospital (CHUV), Lausanne, Switzerland
| | - Emma Ridley
- ANZIC RC, Department of Epidemiology and Preventive Medicine, Monash University, Melbourne, Australia; Nutrition Department, The Alfred Hospital, Melbourne, Australia
| | | | - Oliver Bianchet
- Intensive Care Unit, The Alfred Hospital, Melbourne, Australia
| | | | - Mette M Berger
- Service of Intensive Care Medicine, University Hospital (CHUV), Lausanne, Switzerland.
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Abstract
Severe burn injury is followed by a profound hypermetabolic response that persists up to 2 years after injury. It is mediated by up to 50-fold elevations in plasma catecholamines, cortisol, and glucagon that lead to whole-body catabolism, elevated resting energy expenditures, and multiorgan dysfunction. Modulation of the response by early excision and grafting of burn wounds, thermoregulation, control of infection, early and continuous enteral nutrition, and pharmacologic treatments aimed at mitigating physiologic derangements have markedly decreased morbidity.
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Affiliation(s)
- Felicia N Williams
- Department of Surgery, North Carolina Jaycee Burn Center, University of North Carolina, Chapel Hill, 3007D Burnett Womack Building, CB 7206, Chapel Hill, NC 27599-7206, USA
| | - David N Herndon
- Department of Surgery, Shriners Hospital of Children, University of Texas Medical Branch, 815 Market Street, Galveston, TX 77550, USA.
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25
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Clark A, Imran J, Madni T, Wolf SE. Nutrition and metabolism in burn patients. BURNS & TRAUMA 2017; 5:11. [PMID: 28428966 PMCID: PMC5393025 DOI: 10.1186/s41038-017-0076-x] [Citation(s) in RCA: 95] [Impact Index Per Article: 13.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/19/2017] [Accepted: 03/20/2017] [Indexed: 12/17/2022]
Abstract
Severe burn causes significant metabolic derangements that make nutritional support uniquely important and challenging for burned patients. Burn injury causes a persistent and prolonged hypermetabolic state and increased catabolism that results in increased muscle wasting and cachexia. Metabolic rates of burn patients can surpass twice normal, and failure to fulfill these energy requirements causes impaired wound healing, organ dysfunction, and susceptibility to infection. Adequate assessment and provision of nutritional needs is imperative to care for these patients. There is no consensus regarding the optimal timing, route, amount, and composition of nutritional support for burn patients, but most clinicians advocate for early enteral nutrition with high-carbohydrate formulas. Nutritional support must be individualized, monitored, and adjusted throughout recovery. Further investigation is needed regarding optimal nutritional support and accurate nutritional endpoints and goals.
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Affiliation(s)
- Audra Clark
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
| | - Jonathan Imran
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
| | - Tarik Madni
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
| | - Steven E Wolf
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
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26
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Herndon DN. Southern Surgical Association: A Tradition of Mentorship in Translational Research. J Am Coll Surg 2017; 224:381-395. [DOI: 10.1016/j.jamcollsurg.2016.12.026] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2016] [Accepted: 12/23/2016] [Indexed: 12/11/2022]
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Abstract
Significant weight loss is a common complication of a major burn injury. Before the modern era of early enteral nutrition support, such a complication contributed significantly to impaired wound healing, raised risk of infectious morbidity, and ultimately increased mortality. Nutrition management of the burn patient is designed to promote wound healing while minimizing loss of lean body mass. The burn patient characteristically demonstrates an increase in energy expenditure after the initial injury and period of resuscitation. Studies have demonstrated that early institution of enteral feeding can attenuate the stress response, abate hypermetabolism, and improve patient outcome.
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Affiliation(s)
- Jong O Lee
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, USA.
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28
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Clark A, Imran J, Madni T, Wolf SE. Nutrition and metabolism in burn patients. BURNS & TRAUMA 2017. [PMID: 28428966 DOI: 10.1186/s41038-017-0076-xh] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 05/13/2023]
Abstract
Severe burn causes significant metabolic derangements that make nutritional support uniquely important and challenging for burned patients. Burn injury causes a persistent and prolonged hypermetabolic state and increased catabolism that results in increased muscle wasting and cachexia. Metabolic rates of burn patients can surpass twice normal, and failure to fulfill these energy requirements causes impaired wound healing, organ dysfunction, and susceptibility to infection. Adequate assessment and provision of nutritional needs is imperative to care for these patients. There is no consensus regarding the optimal timing, route, amount, and composition of nutritional support for burn patients, but most clinicians advocate for early enteral nutrition with high-carbohydrate formulas. Nutritional support must be individualized, monitored, and adjusted throughout recovery. Further investigation is needed regarding optimal nutritional support and accurate nutritional endpoints and goals.
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Affiliation(s)
- Audra Clark
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
| | - Jonathan Imran
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
| | - Tarik Madni
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
| | - Steven E Wolf
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd., Dallas, TX 75390 USA
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Porter C, Tompkins RG, Finnerty CC, Sidossis LS, Suman OE, Herndon DN. The metabolic stress response to burn trauma: current understanding and therapies. Lancet 2016; 388:1417-1426. [PMID: 27707498 PMCID: PMC5753602 DOI: 10.1016/s0140-6736(16)31469-6] [Citation(s) in RCA: 186] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Revised: 07/11/2016] [Accepted: 07/21/2016] [Indexed: 12/18/2022]
Abstract
Major burns provoke a profound stress response, which is unrivalled in terms of its magnitude and duration. Evidence suggests that the pathophysiological stress response to severe burn trauma persists for several years after injury. Thus, there is a pressing need for novel strategies that mitigate this response and restore normal metabolic function in patients with burns. This is the first in a Series of three papers about the care of people with burns. In this paper, we review the current knowledge of the stress response to burn trauma, with a focus on hypermetabolism, muscle wasting, and stress-induced diabetes. We highlight recent developments and important knowledge gaps that need to be pursued to develop novel therapeutic strategies to improve outcomes in burn survivors.
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Affiliation(s)
- Craig Porter
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA.
| | - Ronald G Tompkins
- Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Celeste C Finnerty
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA
| | - Labros S Sidossis
- Department of Kinesiology and Health, Rutgers University, New Brunswick, NJ, USA; Department of Medicine, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Oscar E Suman
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, USA; Shriners Hospitals for Children, Galveston, TX, USA
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30
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The efficacy and safety of oxandrolone treatment for patients with severe burns: A systematic review and meta-analysis. Burns 2016; 42:717-27. [DOI: 10.1016/j.burns.2015.08.023] [Citation(s) in RCA: 52] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2015] [Revised: 07/18/2015] [Accepted: 08/16/2015] [Indexed: 11/23/2022]
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33
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Boyer NL, Forbes DA, Chung KK. Practical management of burns and inhalation injury. CURRENT PULMONOLOGY REPORTS 2016. [DOI: 10.1007/s13665-016-0140-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Chapple LAS, Deane AM, Heyland DK, Lange K, Kranz AJ, Williams LT, Chapman MJ. Energy and protein deficits throughout hospitalization in patients admitted with a traumatic brain injury. Clin Nutr 2016; 35:1315-1322. [PMID: 26949198 DOI: 10.1016/j.clnu.2016.02.009] [Citation(s) in RCA: 71] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2015] [Revised: 02/01/2016] [Accepted: 02/10/2016] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND AIMS Patients with traumatic brain injury (TBI) experience considerable energy and protein deficits in the intensive care unit (ICU) and these are associated with adverse outcomes. However, nutrition delivery after ICU discharge during ward-based care, particularly from oral diet, has not been measured. This study aimed to quantify energy and protein delivery and deficits over the entire hospitalization for critically ill TBI patients. METHODS Consecutively admitted adult patients with a moderate-severe TBI (Glasgow Coma Scale 3-12) over 12 months were eligible. Observational data on energy and protein delivered from all routes were collected until hospital discharge or day 90 and compared to dietician prescriptions. Oral intake was quantified using weighed food records on three pre-specified days each week. Data are mean (SD) unless indicated. Cumulative deficit is the mean absolute difference between intake and estimated requirements. RESULTS Thirty-seven patients [45.3 (15.8) years; 87% male; median APACHE II 18 (IQR: 14-22)] were studied for 1512 days. Median duration of ICU and ward-based stay was 13.4 (IQR: 6.4-17.9) and 19.9 (9.6-32.0) days, respectively. Over the entire hospitalization patients had a cumulative deficit of 18,242 (16,642) kcal and 1315 (1028) g protein. Energy and protein intakes were less in ICU than the ward (1798 (800) vs 1980 (915) kcal/day, p = 0.015; 79 (47) vs 89 (41) g/day protein, p = 0.001). Energy deficits were almost two-fold greater in patients exclusively receiving nutrition orally than tube-fed (806 (616) vs 445 (567) kcal/day, p = 0.016) while protein deficits were similar (40 (5) vs 37 (6) g/day, p = 0.616). Primary reasons for interruptions to enteral and oral nutrition were fasting for surgery/procedures and patient-related reasons, respectively. CONCLUSIONS Patients admitted to ICU with a TBI have energy and protein deficits that persist after ICU discharge, leading to considerable shortfalls over the entire hospitalization. Patients ingesting nutrition orally are at particular risk of energy deficit.
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Affiliation(s)
- Lee-Anne S Chapple
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, South Australia, Australia; National Health and Medical Research Council of Australia Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, South Australia, Australia.
| | - Adam M Deane
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, South Australia, Australia; National Health and Medical Research Council of Australia Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, South Australia, Australia; Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia.
| | - Daren K Heyland
- Clinical Evaluation Research Unit, Kingston General Hospital, Kingston, Ontario, Canada.
| | - Kylie Lange
- Discipline of Medicine, University of Adelaide, North Terrace, Adelaide, South Australia, Australia.
| | - Amelia J Kranz
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, South Australia, Australia.
| | - Lauren T Williams
- Menzies Health Institute of Queensland, Griffith University, Queensland, Australia.
| | - Marianne J Chapman
- Discipline of Acute Care Medicine, University of Adelaide, North Terrace, Adelaide, South Australia, Australia; National Health and Medical Research Council of Australia Centre for Clinical Research Excellence in Nutritional Physiology and Outcomes, Level 6, Eleanor Harrald Building, North Terrace, Adelaide, South Australia, Australia; Intensive Care Unit, Level 4, Emergency Services Building, Royal Adelaide Hospital, North Terrace, Adelaide, South Australia, Australia.
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Akers KS, Shields BA, Akers ME, Mende K, Beckius ML, Murray CK, Chung KK. Microbial Contamination of Enteral Nutrition Mixtures in a Hyperthermal Environment: A Follow-Up Investigation. Nutr Clin Pract 2015. [PMID: 26206953 DOI: 10.1177/0884533615586203] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
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Perry J, Stankorb SM, Salgueiro M. Author's Response to "Microbial Contamination of Enteral Nutrition Mixtures in a Hyperthermal Environment: A Follow-Up Investigation". Nutr Clin Pract 2015. [PMID: 26206954 DOI: 10.1177/0884533615586204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Lundy JB, Chung KK, Pamplin JC, Ainsworth CR, Jeng JC, Friedman BC. Update on Severe Burn Management for the Intensivist. J Intensive Care Med 2015; 31:499-510. [PMID: 26112758 DOI: 10.1177/0885066615592346] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2015] [Accepted: 06/01/2015] [Indexed: 11/15/2022]
Abstract
Thermal injury of humans causes arguably the most severe perturbations in physiology that can be experienced. These physiologic derangements start immediately and can persist in some form until months or even years after the burn wounds are healed. Burn shock, marked activation of the systemic inflammatory response, multiple-organ failure, infection, and wound failure are just a few of the insults that may require management by the intensivist. The purpose of this article is to review recent advances in the critical care management of thermally injured patients.
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Affiliation(s)
- Jonathan B Lundy
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Kevin K Chung
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Jeremy C Pamplin
- Burn Center, United States Army Institute of Surgical Research, Fort Sam Houston, TX, USA Department of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD, USA
| | - Craig R Ainsworth
- Department of Medicine, William Beaumont Army Medical Center, Fort Bliss, TX, USA
| | - James C Jeng
- Department of Surgery, Mount Sinai Beth Israel Medical Center, New York, NY, USA
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Shields BA, Brown JN, Aden JK, Salgueiro M, Mann-Salinas EA, Chung KK. A pilot review of gradual versus goal re-initiation of enteral nutrition after burn surgery in the hemodynamically stable patient. Burns 2014; 40:1587-92. [DOI: 10.1016/j.burns.2014.02.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2013] [Revised: 02/14/2014] [Accepted: 02/16/2014] [Indexed: 11/17/2022]
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Xi P, Kaifa W, Yong Z, Hong Y, Chao W, Lijuan S, Hongyu W, Dan W, Hua J, Shiliang W. Establishment and assessment of new formulas for energy consumption estimation in adult burn patients. PLoS One 2014; 9:e110409. [PMID: 25330180 PMCID: PMC4199722 DOI: 10.1371/journal.pone.0110409] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2014] [Accepted: 09/05/2014] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE An accurate knowledge of energy consumption in burn patients is a prerequisite for rational nutrition therapy. This study sought to create a formula that accounts for the metabolic characteristics of adult burn patients to accurately estimate energy consumption of patients with different areas and extents of burn and at different times after injury. METHODS Resting energy expenditure (REE) data on 66 burn patients, with total body surface area (TBSA) of burns ranging from 4% to 96%, were evaluated at different times after injury. REE values were determined in patients using indirect calorimetry at days 1, 2, 3, 7, 14, 21, and 28 after injury. We then constructed a mathematical model of REE changes post-burn. Next, established two new formulas (one non-linear and the other linear) for energy consumption estimation using model-based analytical solution and regression analysis. The new formulas were compared with measured REE and commonly used formulas including those of Carlson, Xie, Curreri, and Milner to determine accuracy and reliability. RESULTS Comparative analysis showed that the new formulas offered significantly higher accuracy and reliability than the Milner formula, which is considered the most accurate of commonly used burn energy consumption estimate formulas. The accuracy of the new nonlinear formula (94.29%) and that of the linear formula (91.43%) were significantly higher than that of Milner formula (72.86%) when compared to measured REE (χ2 = 11.706, P = 0.001; χ2 = 8.230, P = 0.004, respectively). The reliabilities of the new estimation formulas were both 100% and that of Milner formula was 74.24% (χ2 = 19.513, P = 0.000). CONCLUSION The new formulas constructed in this study provide reliable simulation of the impact of the degree of burn and post-burn days on energy consumption and offer notably higher accuracy and reliability than other formulas. These formulas will help determine nutritional needs of burn patients. TRIAL REGISTRATION The study was registered on Chinese Clinical Trial Registry as ChiCTR-TRC-13003806.
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Affiliation(s)
- Peng Xi
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burns of PLA, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Wang Kaifa
- Department of Mathematics, School of Biomedical Engineering, Third Military Medical University, Chongqing, P.R. China
| | - Zhang Yong
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burns of PLA, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Yan Hong
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burns of PLA, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Wang Chao
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burns of PLA, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Song Lijuan
- Department of Mathematics, School of Biomedical Engineering, Third Military Medical University, Chongqing, P.R. China
| | - Wang Hongyu
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burns of PLA, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Wu Dan
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burns of PLA, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
| | - Jiang Hua
- Department of Computational Mathematics and Biostatistics, Metabolomics and Multidisciplinary Laboratory for Trauma Research, Sichuan Provincial People's Hospital, Sichuan Academy of Medical Sciences, Chengdu, China
| | - Wang Shiliang
- State Key Laboratory of Trauma, Burns and Combined Injury, Institute of Burns of PLA, Southwest Hospital, Third Military Medical University, Chongqing, P.R. China
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Perry J, Stankorb SM, Salgueiro M. Microbial Contamination of Enteral Feeding Products in Thermoneutral and Hyperthermal ICU Environments. Nutr Clin Pract 2014; 30:128-33. [DOI: 10.1177/0884533614541680] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Affiliation(s)
- Jeffery Perry
- Military-Baylor Graduate Program in Nutrition, JBSA Fort Sam Houston, Texas
- Brooke Army Medical Center, San Antonio, Texas
| | - Susan M. Stankorb
- Military-Baylor Graduate Program in Nutrition, JBSA Fort Sam Houston, Texas
- Brooke Army Medical Center, San Antonio, Texas
| | - Marybeth Salgueiro
- Military-Baylor Graduate Program in Nutrition, JBSA Fort Sam Houston, Texas
- Brooke Army Medical Center, San Antonio, Texas
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Przkora R, Fram RY, Herndon DN, Suman OE, Mlcak RP. Influence of inhalation injury on energy expenditure in severely burned children. Burns 2014; 40:1487-91. [PMID: 24893760 DOI: 10.1016/j.burns.2014.04.019] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2013] [Revised: 04/12/2014] [Accepted: 04/16/2014] [Indexed: 10/25/2022]
Abstract
OBJECTIVE Determine the effect of inhalation injury on burn-induced hypermetabolism in children. DESIGN Prospective study comparing hypermetabolism (i.e., resting energy expenditure and oxygen consumption) in burned children with and without inhalation injury during acute hospitalization. SETTING Single pediatric burn center. PATIENTS Eighty-six children (1-18 years) with ≥40% total body surface area burns were stratified to two groups: no inhalation injury and inhalation injury. INTERVENTIONS None. MAIN MEASUREMENTS AND RESULTS Inhalation injury was diagnosed based on bronchoscopic evaluation. At admission, PaO2:FiO2 ratios (an index of respiratory distress) were significantly higher in patients with no inhalation injury than in patients with inhalation injury. No differences were detected in resting energy expenditure or percent of the predicted basal metabolic rate between groups. Additionally, oxygen consumption did not significantly differ between groups. CONCLUSIONS Inhalation injury does not augment the burn-induced hypermetabolic stress response in children, as reflected by resting energy expenditure and oxygen consumption.
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Affiliation(s)
- Rene Przkora
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, United States; Shriners Hospitals for Children, Galveston, TX, United States; Department of Anesthesiology, University of Texas Medical Branch, Galveston, TX, United States.
| | - Ricki Y Fram
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, United States; Shriners Hospitals for Children, Galveston, TX, United States
| | - David N Herndon
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, United States; Shriners Hospitals for Children, Galveston, TX, United States
| | - Oscar E Suman
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, United States; Shriners Hospitals for Children, Galveston, TX, United States
| | - Ronald P Mlcak
- Department of Surgery, University of Texas Medical Branch, Galveston, TX, United States; Shriners Hospitals for Children, Galveston, TX, United States.
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Occurrence of multiorgan dysfunction in pediatric burn patients: incidence and clinical outcome. Ann Surg 2014; 259:381-7. [PMID: 23511841 DOI: 10.1097/sla.0b013e31828c4d04] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To examine the incidence of single or multiple organ failure postburn and its resultant clinical outcomes during acute hospitalization. BACKGROUND Patient outcomes are inherently dependent on intact organ function; however, burn injury affects the structure and function of almost every organ, but especially lung, liver, kidney, and heart. Therefore, single-organ failure and/or multiorgan failure (MOF) are thought to contribute significantly to postburn morbidity and mortality, but to date no large trial examining the effects of MOF on postburn outcomes exists. METHODS Incidence of MOF was monitored in 821 pediatric burn patients during acute hospitalization. Patients were divided into groups on the basis of the incidence of single-organ-specific failure, MOF, and non-MOF. The DENVER2 score was used to assess organ-specific scores for lung, liver, kidney, and heart. The patient's demographics, injury characteristics, and outcome parameters were recorded. RESULTS Respiratory failure has the highest incidence in the early phase of postburn injury and decreases starting 5 days postburn. Cardiac failure was noted to have the highest incidence throughout hospital stay. Incidence of hepatic failure increases with the hospital length of stay and is associated with a high mortality during the late phase of the acute hospital stay. Renal failure has an unexpectedly low incidence but is associated with a high mortality during the first 3 weeks postburn injury. Three or more organ failure is associated with very high mortality. CONCLUSIONS This is the first large study in burn patients to determine the incidence of organ-specific failure and outcome. The results of this study confirmed the expected chronologic incidence of organ-specific failure and yield the long-term mortality from liver and renal failure.
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Jeschke MG, Williams FN, Finnerty CC, Rodriguez NA, Kulp GA, Ferrando A, Norbury WB, Suman OE, Kraft R, Branski LK, Al-mousawi AM, Herndon DN. The effect of ketoconazole on post-burn inflammation, hypermetabolism and clinical outcomes. PLoS One 2012; 7:e35465. [PMID: 22606232 PMCID: PMC3350497 DOI: 10.1371/journal.pone.0035465] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2011] [Accepted: 03/19/2012] [Indexed: 11/19/2022] Open
Abstract
Background Hypercortisolemia has been suggested as a primary hormonal mediator of whole-body catabolism following severe burn injury. Ketoconazole, an anti-fungal agent, inhibits cortisol synthesis. We, therefore, studied the effect of ketoconazole on post-burn cortisol levels and the hyper-catabolic response in a prospective randomized trial (block randomization 2∶1). Methodology/Principal Findings Fifty-five severely burned pediatric patients with >30% total body surface area (TBSA) burns were enrolled in this trial. Patients were randomized to receive standard care plus either placebo (controls, n = 38) or ketoconazole (n = 23). Demographics, clinical data, serum hormone levels, serum cytokine expression profiles, organ function, hypermetabolism measures, muscle protein synthesis, incidence of wound infection sepsis, and body composition were obtained throughout the acute hospital course. Statistical analysis was performed using Fisher’s exact test, Student’s t-test, and parametric and non-parametric two-way repeated measures analysis of variance where applicable. Patients were similar in demographics, age, and TBSA burned. Ketoconazole effectively blocked cortisol production, as indicated by normalization of the 8-fold elevation in urine cortisol levels [F(1, 376) = 85.34, p<.001] with the initiation of treatment. However, there were no significant differences in the inflammatory response, acute-phase proteins, body composition, muscle protein breakdown or synthesis, or organ function between groups. Conclusions Both groups were markedly hypermetabolic and catabolic throughout the acute hospital stay. Normalization of hypercortisolemia with ketoconazole therapy had no effect on whole-body catabolism or the post-burn inflammatory or hypermetabolic response, suggesting that hypercortisolemia does not play a central role in the post-burn hypermetabolic catabolic response. Trial Registration ClinicalTrials.gov NCT00675714; and NCT00673309
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Affiliation(s)
- Marc G. Jeschke
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Felicia N. Williams
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Celeste C. Finnerty
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
- Institute for Translational Sciences and the Sealy Center for Molecular Medicine, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Noe A. Rodriguez
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Gabriela A. Kulp
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Arny Ferrando
- University of Arkansas for Medical Sciences, Little Rock, Arkansas, United States of America
| | - William B. Norbury
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Oscar E. Suman
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Robert Kraft
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Ludwik K. Branski
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - Ahmed M. Al-mousawi
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
| | - David N. Herndon
- Shriners Hospitals for Children, University of Texas Medical Branch, Galveston, Texas, United States of America
- Department of Surgery, University of Texas Medical Branch, Galveston, Texas, United States of America
- * E-mail:
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Abstract
Amino-N is preserved because of the scarcity and nutritional importance of protein. Excretion requires its conversion to ammonia, later incorporated into urea. Under conditions of excess dietary energy, the body cannot easily dispose of the excess amino-N against the evolutively adapted schemes that prevent its wastage; thus ammonia and glutamine formation (and urea excretion) are decreased. High lipid (and energy) availability limits the utilisation of glucose, and high glucose spares the production of ammonium from amino acids, limiting the synthesis of glutamine and its utilisation by the intestine and kidney. The amino acid composition of the diet affects the production of ammonium depending on its composition and the individual amino acid catabolic pathways. Surplus amino acids enhance protein synthesis and growth, and the synthesis of non-protein-N-containing compounds. But these outlets are not enough; consequently, less-conventional mechanisms are activated, such as increased synthesis of NO∙ followed by higher nitrite (and nitrate) excretion and changes in the microbiota. There is also a significant production of N(2) gas, through unknown mechanisms. Health consequences of amino-N surplus are difficult to fathom because of the sparse data available, but it can be speculated that the effects may be negative, largely because the fundamental N homeostasis is stretched out of normalcy, forcing the N removal through pathways unprepared for that task. The unreliable results of hyperproteic diets, and part of the dysregulation found in the metabolic syndrome may be an unwanted consequence of this N disposal conflict.
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Masters B, Aarabi S, Sidhwa F, Wood F. High-carbohydrate, high-protein, low-fat versus low-carbohydrate, high-protein, high-fat enteral feeds for burns. Cochrane Database Syst Rev 2012; 1:CD006122. [PMID: 22258965 DOI: 10.1002/14651858.cd006122.pub3] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND Severe burn injuries increase patients' metabolic needs. Aggressive high-protein enteral feeding is used in the post-burn period to improve recovery and healing. OBJECTIVES To examine the evidence for improved clinical outcomes in burn patients treated with high-carbohydrate, high-protein, low-fat enteral feeds (high-carbohydrate enteral feeds) compared with those treated with low-carbohydrate, high-protein, high-fat enteral enteral feeds (high-fat enteral feeds). SEARCH METHODS We searched the Cochrane Injuries Group Specialised Register (searched 28 Nov 2011), Cochrane Central Register of Controlled Trials (The Cochrane Library 2011, Issue 4), MEDLINE (Ovid) 1950 to Nov (Week 3) 2011, EMBASE (Ovid), ISI Web of Science: Science Citation Index Expanded (SCI-EXPANDED) (1970 to Nov 2011), ISI Web of Science: Conference Proceedings Citation Index-Science (CPCI-S) (1990 to Nov 2011), PubMed (Searched 28 Nov 2011). Online trials registers and conference proceedings were also searched to April 2010. SELECTION CRITERIA We included all randomized controlled trials (RCTs) comparing high-carbohydrate enteral feeds to high-fat enteral feeds for treatment of patients with 10% or greater total body surface area (TBSA) burns in the immediate post-burn period, with data for at least one of the pre-specified outcomes. DATA COLLECTION AND ANALYSIS Two authors collected and analysed the following data: mortality, incidence of pneumonia and days on ventilator. Meta-analysis could only be performed for the outcomes mortality and incidence of pneumonia. A random-effects model was used for all comparisons. MAIN RESULTS Two RCTs, reporting results from 93 patients, were included in this review. Patients given a high-carbohydrate feeding formula had an odds ratio (OR) of 0.12 (95% confidence interval (CI) 0.04 to 0.39) for developing pneumonia compared to patients given a high-fat enteral formula (P value = 0.0004). Patients given a high-carbohydrate formula had an OR of 0.36 (95% CI 0.11 to 1.15) for risk of death compared to patients given a high-fat enteral formula; this difference did not reach statistical significance (P value = 0.08). Risk of bias in these studies was assessed as high and moderate. AUTHORS' CONCLUSIONS The available evidence suggests that use of high-carbohydrate, high-protein, low-fat enteral feeds in patients with at least 10% TBSA burns might reduce the incidence of pneumonia compared with use of a low-carbohydrate, high-protein, high-fat diet. The available evidence is inconclusive regarding the effect of either enteral feeding regimen on mortality. Note that the available evidence is limited to two small studies judged to be of moderate risk of bias. Further research is needed in this area before strong conclusions can be drawn.
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Affiliation(s)
- Bronwen Masters
- Sports Institute Northern Ireland, University of Ulster, Newtownabbey, Northern Ireland, BT370QB, UK.
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Abstract
Stress hyperglycemia (SH) commonly occurs during critical illness in children. The historical view that SH is beneficial has been questioned in light of evidence that demonstrates the association of SH with worse outcomes. In addition to intrinsic changes in glucose metabolism and development of insulin resistance, specific intensive care unit (ICU) practices may influence the development of SH during critical illness. Mechanical ventilation, vasoactive infusions, renal replacement therapies, cardiopulmonary bypass and extracorporeal life support, therapeutic hypothermia, prolonged immobility, nutrition support practices, and the use of medications are all known to mediate development of SH in critical illness. Tight glucose control (TGC) to manage SH has emerged as a promising therapy to improve outcomes in critically ill adults, but results have been inconclusive. Large variations in ICU practices across studies likely resulted in inconsistent results. Future studies of TGC need to take into account the impact of commonly used ICU practices and, ideally, standardize protocols in an attempt to improve the accuracy of conclusions from such studies.
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Affiliation(s)
- Vijay Srinivasan
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Philadelphia, Pennsylvania 19104, USA.
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Sugita M, Sugita H, Kim M, Mao J, Yasuda Y, Habiro M, Shinozaki S, Yasuhara S, Shimizu N, Martyn JJ, Kaneki M. Inducible nitric oxide synthase deficiency ameliorates skeletal muscle insulin resistance but does not alter unexpected lower blood glucose levels after burn injury in C57BL/6 mice. Metabolism 2012; 61:127-36. [PMID: 21816442 PMCID: PMC3304504 DOI: 10.1016/j.metabol.2011.06.001] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/16/2011] [Revised: 05/30/2011] [Accepted: 06/02/2011] [Indexed: 01/04/2023]
Abstract
Burn injury is associated with inflammatory responses and metabolic alterations including insulin resistance. Impaired insulin receptor substrate-1 (IRS-1)-mediated insulin signal transduction is a major component of insulin resistance in skeletal muscle following burn injury. To further investigate molecular mechanisms that underlie burn injury-induced insulin resistance, we study a role of inducible nitric oxide synthase (iNOS), a major mediator of inflammation, on burn-induced muscle insulin resistance in iNOS-deficient mice. Full-thickness third-degree burn injury comprising 12% of total body surface area was produced in wild-type and iNOS-deficient C57BL/6 mice. Insulin-stimulated activation (phosphorylation) of IR, IRS-1, and Akt was assessed by immunoblotting and immunoprecipitation. Insulin-stimulated glucose uptake by skeletal muscle was evaluated ex vivo. Burn injury caused induction of iNOS in skeletal muscle of wild-type mice. The increase of iNOS expression paralleled the increase of insulin resistance, as evidenced by decreased tyrosine phosphorylation of IR and IRS-1, IRS-1 expression, insulin-stimulated activation of phosphatidylinositol 3-kinase and Akt/PKB, and insulin-stimulated glucose uptake in mouse skeletal muscle. The absence of iNOS in genetically engineered mice significantly lessened burn injury-induced insulin resistance in skeletal muscle. In wild-type mice, insulin tolerance test revealed whole-body insulin resistance in burned mice compared with sham-burned controls. This effect was reversed by iNOS deficiency. Unexpectedly, however, blood glucose levels were depressed in both wild-type and iNOS-deficient mice after burn injury. Gene disruption of iNOS ameliorated the effect of burn on IRS-1-mediated insulin signaling in skeletal muscle of mice. These findings indicate that iNOS plays a significant role in burn injury-induced skeletal muscle insulin resistance.
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Affiliation(s)
- Michiko Sugita
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Shriners Hospitals for Children, Boston, MA 02114, USA
| | - Hiroki Sugita
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Shriners Hospitals for Children, Boston, MA 02114, USA
| | - Minhye Kim
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Ji Mao
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Shriners Hospitals for Children, Boston, MA 02114, USA
| | - Yoshikazu Yasuda
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Shriners Hospitals for Children, Boston, MA 02114, USA
| | - Mayu Habiro
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
| | - Shohei Shinozaki
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Shriners Hospitals for Children, Boston, MA 02114, USA
| | - Shingo Yasuhara
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Shriners Hospitals for Children, Boston, MA 02114, USA
| | - Nobuyuki Shimizu
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Shriners Hospitals for Children, Boston, MA 02114, USA
| | - J.A. Jeevendra Martyn
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Shriners Hospitals for Children, Boston, MA 02114, USA
| | - Masao Kaneki
- Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA 02114, USA
- Shriners Hospitals for Children, Boston, MA 02114, USA
- Corresponding author. Masao Kaneki; Department of Anesthesia, Critical Care, and Pain Medicine, Massachusetts General Hospital, Harvard Medical School, 149 Thirteenth Street, Charlestown, MA 02129, USA, Phone: +1(617) 726-8122; Fax: +1(617) 726-8134;
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Rodriguez NA, Jeschke MG, Williams FN, Kamolz LP, Herndon DN. Nutrition in burns: Galveston contributions. JPEN J Parenter Enteral Nutr 2011; 35:704-14. [PMID: 21975669 PMCID: PMC3778650 DOI: 10.1177/0148607111417446] [Citation(s) in RCA: 89] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Aggressive nutrition support is recommended following severe burn injury. Initially, such injury results in a prolonged and persistent hypermetabolic response mediated by a 10- to 20-fold elevation in plasma catecholamines, cortisol, and inflammatory mediators. This response leads to twice-normal metabolic rates, whole-body catabolism, muscle wasting, and severe cachexia. Thus, it is relevant to review the literature on nutrition in burns to adjust/update treatment. Failure to meet the increased substrate requirements may result in impaired wound healing, multiorgan dysfunction, increased susceptibility to infection, and death. Therefore, aggressive nutrition support is essential to ensure adequate burn care, attenuate the hypermetabolic response, optimize wound healing, minimize devastating catabolism, and reduce morbidity and mortality. Here, the authors provide nutrition recommendations gained from prospective trials, retrospective analyses, and expert opinions based on the authors' practices in Galveston, Texas, and Vienna, Austria.
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Affiliation(s)
- Noe A. Rodriguez
- Department of Surgery, The University of Texas Medical Branch and Shriners Hospitals for Children–Galveston, Galveston, Texas
| | - Marc G. Jeschke
- Department of Surgery, The University of Texas Medical Branch and Shriners Hospitals for Children–Galveston, Galveston, Texas
- Department of Surgery, University of Toronto, Toronto, Canada
| | - Felicia N. Williams
- Department of Surgery, The University of Texas Medical Branch and Shriners Hospitals for Children–Galveston, Galveston, Texas
| | - Lars-Peter Kamolz
- Division of Plastic and Reconstructive Surgery, Department of Surgery, Medical University of Vienna, Vienna, Austria
- Section of Plastic and Reconstructive Surgery, Department of Surgery, Landesklinikum Wiener Neustadt, Wiener Neustadt, Austria
| | - David N. Herndon
- Department of Surgery, The University of Texas Medical Branch and Shriners Hospitals for Children–Galveston, Galveston, Texas
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Williams FN, Branski LK, Jeschke MG, Herndon DN. What, how, and how much should patients with burns be fed? Surg Clin North Am 2011; 91:609-29. [PMID: 21621699 DOI: 10.1016/j.suc.2011.03.002] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
The hypermetabolic response to severe burn injury is characterized by hyperdynamic circulation and profound metabolic, physiologic, catabolic, and immune system derangements. Failure to satisfy overwhelming energy and protein requirements after, and during, severe burn injury results in multiorgan dysfunction, increased susceptibility to infection, and death. Attenuation of the hypermetabolic response by various pharmacologic modalities is emerging as an essential component of the management of patients with severe burn injury. This review focuses on the more recent advances in therapeutic strategies to attenuate the hypermetabolic response and its postburn-associated insulin resistance.
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Affiliation(s)
- Felicia N Williams
- Department of Surgery, Shriners Hospital for Children and University of Texas Medical Branch, 815 Market Street, Galveston, TX 77550, USA
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Abstract
Cardiac stress, mediated by increased catecholamines, is the hallmark of severe burn injury typified by marked tachycardia, increased myocardial oxygen consumption, and increased cardiac output (CO). It remains one of the main determinants of survival in large burns. Currently, it is unknown for how long cardiac stress persists after a severe injury. Therefore, the aim of this study was to determine the extent and duration of cardiac stress after a severe burn. To determine persistence of cardiac alteration, the authors determined cardiac parameters of all surviving patients with burns ≥ 40% TBSA from 1998 to 2008. One hundred ninety-four patients were included in this study. Heart rate, mean arterial pressure, CO, stroke volume, cardiac index, and ejection fractions were measured at regular intervals from admission up to 2 years after injury. Rate pressure product was calculated as a correlate of myocardial oxygen consumption. All values were compared with normal nonburned children to validate the findings. Statistical analysis was performed using log transformed analysis of variance with Bonferroni correction and Student's t-test, where applicable. Heart rate, CO, cardiac index, and rate pressure product remained significantly increased in burned children for up to 2 years when compared with normal ranges (P < .05), indicating vastly increased cardiac stress. Ejection fraction was within normal limits for 2 years. Cardiac stress persists for at least 2 years postburn, and the authors suggest that attenuation of these detrimental responses may improve long-term morbidity.
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