MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

I: Understanding the Diagnosis and Pathophysiology

1) Describe how burn wounds are classified. Identify and describe Mr. Angelos burn injuries.
Burn wounds are classified in three ways: by cause or etiology, by depth, and by size or extent.1
According to the Nutrition Care Manual, the causal or etiological classifications for burn wounds are flame,
scald, contact, electrical, or chemical burns.1 Depth classification is determined by how deep the burn has
penetrated the skin. Table 1 (below) summarizes the criteria for measuring and classifying the depth of burn
wounds. Classification by extent refers to how much of the total body surface area (TBSA) is covered by burn
wounds. The size or extent of burn injuries is often estimated using the rule of nines explained in Question 2
below. Erythema should not be counted when calculating burn size.2 Burns covering more than 10% of a
patients TBSA should be referred to a burn center that provides specialized treatment, including nutrition
care.1
Mr. Angelo has thermal flame burns of various degrees covering approximately 40% of his body. He
has burns on his entire face as well as singed eyebrows, hair, and facial hair. There are first degree burns near
his umbilicus and second degree burns over his mid, left, and lower back; buttocks; abdomen; and bilateral
upper extremities. He has also had blistering over his scrotum and the head of his penis, which is indicative of
second degree burns.3 There are third degree burns circumferentially on his bilateral lower extremities.
Table 1
Classification of burn wounds by deptha
DEPTH OF BURN

SKIN THICKNESS

TISSUE LAYER

0.010

Epidermis

0.020

Dermis

0.035

Subcutaneous Tissue

0.040

Muscle

Adapted from reference 3.

2) Explain the rule of nines used in assessment of burn injury.

The rule of nines is a common method for classifying burn injuries by size or extent. It allows medical
professionals to quickly estimate the percentage of a patients body that has been burned by dividing the body
into sections that each represent approximately 9% of the patients TBSA, then totaling the percentages from
the burned sections.2 Table 2 (below) summarizes the major body sections that are evaluated when applying
the rule of nines.4 These percentages are not applicable for children because their heads are proportionally
larger and their legs are proportionately smaller than those of adults.2,4

MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

Table 2
Summary of body regions used to apply the rule of ninesa
BODY SECTION

PROPORTION OF TBSA

Head and neck

9%

Anterior torso

18%

Posterior torso

18%

Arms

9% each

Legs

18% each

Genitalia

1%

Adapted from reference 4.

3) Mr. Angelos fluid resuscitation order was: LR @ 610 mL/hr X first 8 hours and decrease to 305
mLd/hr X 16 hours. What is the primary goal of fluid resuscitation? Briefly explain the Parkland
formula. What common intravenous fluid is used in burn patients for fluid resuscitation? What
are the components of this solution?
Of utmost importance within the first 24 to 48 hours is fluid resuscitation, particularly since nutrition
support for trauma patients is only possible after stabilization.3 The evaporation of fluid from wounds ranges
from 2 to 3.1 mL/kg of body weight per 24 hours per percent of TBSA burn.3 Additionally, the edema that
occurs after a burn injury can lead to hypovolemia. Without an influx of fluids to help properly distribute oxygen
through the body, end-organ hypoperfusion and ischemia result.5 This, of course, doesnt include the amount
of fluid needed for body maintenance. Thus, fluid needs are expected to be elevated in the burn patient.
One method to calculate needs is the Parkland formula. A 2010 review found that 78% of burn units in
the United Kingdom, Ireland, United States, and Canada use this formula to determine fluid needs.5 The
Parkland formula recommends providing Ringers Lactated (RL) solution in volume 4 mL/kg/%burn for adults in
the first 24 hours.5 Then, colloids are provided as 20-60% of calculated plasma volume.5 Glucose is added to
the water in amounts sufficient to produce 0.5 to 1 mL/hour urinary output in adults.5 Typically, the first half of
calculated fluid is delivered within the first 8 hours and then the second 50% of calculated fluid volume is
delivered over a 16-hour period.3
RL is the type of fluid provided to burn patients. It provides the following:6
Sodium Chloride 600 mg per 100 mL
Sodium Lactate 310 mg in 100 mL
Potassium Chloride 30 mg per 100 mL
Calcium Chloride 20 mg per 100 mL
4) ***SKIPPED per instructor guidelines***

MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

5) Burns are often described as one of the most metabolically stressful injuries. Discuss the
effects of a burn on metabolism and how this will affect nutritional requirements.
Burns trigger several processes in the body which affect nutritional requirements. Severe burns
compromising more than 20% of TBSA trigger inflammation, protein catabolism, and a hypermetabolic state.7
Although burn patients are similar to other critically ill patients by nature, their injuries result in unique
nutritional recommendations. The loss of skin area is one reason for the metabolic change seen in burn
victims. By increasing evaporative losses of water the body also loses radiative heat.8 Additionally, protein
exits the body through fluid secretions of the damaged skin.3 Thus, the patient has elevated requirements for
fluids, energy, and protein due to skin damage.
Protein is affected by other changes to metabolism after a burn. Muscle is catabolized and amino acids
from its proteins are re-directed to creating acute-phase proteins or to heal wounds.8 Additionally, there is an
increased urinary nitrogen output secondary to the increased hypermetabolic state.3 Thus, several areas of
the body are affected in a burn, all of which elevate the need for protein. The current consensus is that patients
should receive protein as 20-25% of their daily caloric intake, particularly proteins that have high biological
value.3 Protein requirements can also be expressed as being 1.5 to 2.0 g/kg/day.9
Carbohydrates are able to assist in the healing process. By activating the insulin response CHO intake
can promote an anabolic state, which counters the catabolism that occurs after burns.8 In fact, part of the
bodys natural response to trauma is to induce gluconeogenesis and oxidize BCAA to produce more sugar in
the body.3 This supply of glucose is important for providing energy to cells so that they may initiate repair
processes. Although carbohydrates can form up to 65% of the daily calories that a healthy adult consumes
CHO intake must be monitored in the burn patient, however. Providing excess glucose to a person already in a
state of hyperglycemia could be dangerous. Current evidence suggests limiting CHO to 5 mg/kg/min, which is
equal to about 50% of kcal coming from CHO.7,9
Not much evidence has been collected on fat to date, but this should also be monitored. Research
shows that patients receiving over 35% of calories from fat have longer hospital stays and increased risk of
infection.7 But, some lipids are required to prevent essential fatty acid deficiency. Therefore, current guidelines
recommend 15 - 20% of fat as an optimal goal.9
In general, burn patients experience increased nutrient needs, particularly for calories and protein.
Resting energy expenditure requirements can increase by up to 100% depending on the scope of injury.3 On
the other hand, care must be taken not to overfeed patients as this is associated with complications for the
critically ill population. Negative outcomes of overfeeding include hyperglycemia, hepatic steatosis, and excess
CO2 production, which can overload the pulmonary system.3
6) List all medications that Mr. Angelo is receiving. Identify the action of each medication and any
drug-nutrient interactions that you should monitor.
Mr. Angelo is currently receiving a large assortment of medications. The following table summarizes his
scheduled and PRN medications, including brief descriptions of the action and potential drug-nutrient
interactions (DNIs) for each.3,10-13

MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

Table 3
Summary of patients current medicationsa
MEDICATION

ACTION

DNI

Ascorbic acid, 500 mg q 12 hrs

Antioxidant. Required for

Doses higher than 1 g/day
synthesis of collagen by
can lead to N/V, dyspepsia,
acting as a reducing agent gastric cramps, and diarrhea.
for Fe. Also aids immune
function and proper lung
function.

Chlorhexidine, 0.12% oral soln

15 mL q 12 hrs

Mouthwash solution that

treats or prevents
gingivitis through antibacterial action.

No food PO or water several

hours after rinse. A water
rinse immediately after
intensifies the bitter taste of
the medicine. Dysgeusia up
to 4 hrs after dose is taken.

Famotidine, tab 20 mg q 12 hrs

Anti-ulcer, Anti-GERD

N/V, diarrhea, constipation,

dec gastric acid sec, inc
gastric pH, 2 hrs between Fe
suppl, Mg or Al/Mg antacid
also 2 hrs

Heparin, injection 5,000 units q

8 hrs

Anti-coagulant. Prevents
blood clots from forming
as well as stopping preexisting ones from
growing in size.

N/A

Insulin, injection q 6 hrs

Antidiabetic,
hypoglycemic.

Inc wt. With severe

hypoalbuminemia, leads to
toxicity since insulin determir
is 98% serum bound.

Multivitamin (MVI), tab 1 daily

Provides multiple vitamins

and minerals to
supplement those lacking
in the diet and support
wound heading increased
metabolism following
major trauma.

Amounts from MVI, in

combination with other
supplements and dietary
intake, may exceed toxicity
limits depending on brand.
Minerals in MVI may interact
with minerals from other
sources to dec absorption.

MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

Zinc sulfate, 220 mg daily

Plays a role in over 300

enzymatic reactions,
mostly involving
metabolism of
macronutrients and
nucleic acids. Levels are
high in the nucleus,
stabilizing RNA
polymerases which are
crucial for cell division.

Dec levels w/ burns or trauma

and prolonged TPN,
hypoalbuminemia. A diet high
in protein increases
bioavailability. High doses
may interfere with the ability
to absorb Fe from dietary
supplements.

Methadone, 10 mg q 8 hrs

Analgesic, Narcotic,
Opioid.

Caution w/ grapefruit/related
citrus. Anorexia, dry mouth,
N/V, cramps, constipation.
Caution w/ asthma or
bronchospasm. Respiratory
depression, drowsiness,
dizziness, sedation, edema.

Oxandrolone, 10 mg q 12 hrs

Anti-wasting, Anabolic
Must have adequate cal and
steroid. Promote wt gain
protein intake for anabolic
after trauma, offset protein effect. N/V, diarrhea.
catabolism.

Senna, tab 8.6 mg daily

Laxative, stimulation

Electrolyte imbalance with

excessive use. Inc intestional
perstalsis, BM in 6-12 hr. NV/
cramps, diarrhea. Inc
glucose, dec K and Ca w/ LT
use. High fiber with 1.5-2k
mL/fluid to prevent
constipation.

Docusate, oral liq 100 mg q 12

hrs

Stool softener, laxative

High fiber with 1.5-2k mL/fluid

to prevent constipation. Mix
liquid w/ 6-8 oz. milk or juice
to mask bitter taste, prevent
throat irritation. Alters
intestinal abs of water and
electrolytes. Nausea. Inc
glucose and K w/ LT use.

Silver sulfadiazine, 1% cream

topical application daily

Antibiotic prescribed to
prevent and treat
infections for second and
third degree burns.

N/A

Acetaminophen, 650 mg oral q

4 hrs prn

Analgesic, antipyretic.

Pt has known allergy to

Tylenol.

MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

Midazolam HCl (Versed), 100

mg in NaCl 0.9% 100 mL IV
infusion, intiate 1 mg/hr

Anesthesia adjunct,
sedative. Antianxiety,
skeletal muscle relaxation,
antipanic, sleep aid.

Caution w/ grapefruit/related
citrus. Caution w/ sedative or
stimulant products (caffeine,
chamomile, e.g.). Anorexia,
dec wt and appetite.
Hypoalbuminemia (<3 g/dL)
may increase drug effect b/c
albumin-bound. CNS
depression effects.

Hydromorphone (Dilaudid),
injection 0.5 to 1 mg, IV q 3 hrs
prn

Analgesic, antitussive,
narcotic, opioid.

Anorexia, wt dec, inc thirst,

dehydration. Dry mouth, dec
gastric motility, N/V,
constipation, impaction,
diarrhea. Respiratory
depression, apnea,
drowsiness, dec cough reflex,
CNS depression symptoms.
Inc urinary retention in males.

Fentanyl (Sublimaze), injection

50 to 100 mcg IV q 15 min prn

Analgesic, Narcotic,
Opioid.

Anorexia. Dry mouth,

dyspepsia, N/V. Caution with
dec pulmonary func. CNS
depression symptoms.
Dyspnea. Dec or Inc BP.

Propofol (Diprivan), 25 mL/hr

IV continuous

Anesthesia, Sedative. ICU

sedation for intubated
and/or mechanically
ventilated pt.

With use > 72 hr, low-fat diet,

low fat EN or TPN. Caution
with diabetes. HTN,
decreased pulmonary
function, pulmonary edema
(rare). Increased urinary Zn
excretion.

Thiamin, 100 mg x 3 days

B complex vitamin. Coenzyme for several

reactions in energy
metabolism, e.g. oxidation
of pyruvate to acetyl CoA.

IV administration can lead to

nausea.

Folate, 1 mg x 3 days

B complex vitamin,
antianemic. Plays major
role in synthesis and
repair of DNA. Also
important for red and
white blood cell formation.

Deficiencies of Vitamin B12

and C or Fe can inhibit proper
folate metabolism.

Adapted from references 3 and 10-13.

II: Understanding the Nutrition Therapy

6

MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

7) Using evidence-based guidelines, describe the potential benefits of early enteral nutrition in
burn patients.
According to the Nutrition Care Manual, early enteral nutrition is a safe and effective way to provide
adult as well as child burn patients with the nutrition they critically need.1 Early initiation of EN offers many
potential health benefits for burn patients, including provision of nutrient needs, improved tube feeding
tolerance, decreased length of stay, decreased incidence of bacterial translocation, decreased number of
infectious episodes, decreased need for antibiotic therapy, improved nitrogen balance, reduced urinary
catecholamines, diminished serum glucagon, suppressed hypermetabolic response, and enhanced visceral
protein status.1,14 Early EN is believed to help preserve gut integrity and function as well as to control the
widespread stress and immune responses to trauma.15 In adult ICU patients, early initiation of EN has been
associated with reduced gut permeability as well as decreased activation and release of cytokines.15 Specific
EN formulations can even be used to prevent stress ulcers and alter immune response following major
trauma.15
8) What are the common criteria used to assess readiness for the initiation of enteral nutrition in
burn patients?
According to the Nutrition Care Manual, enteral nutrition should only be initiated in burn patients who
are expected to be unable to meet energy and protein needs via PO intake (less than 75% of needs) for longer
than 3 days.1 This generally includes burn patients with body surface area burn (BSAB) greater than 20%
and/or those with inhalation injuries that make ventilator support necessary.1 To be ready for initiation of EN,
burn patients must have completed fluid resuscitation; be hemodynamically stable; not be receiving
vasoconstrictors (e.g., levophed or dopamine); and not be suffering from high abdominal pressures or lactic
acidosis.1 Other general criteria for the suitability of EN also apply here. There must be appropriate enteral
access for the patient; the patient should not be vomiting; and the patient should have a soft, tender abdomen
and functional GI tract with no signs of ileus or obstruction prior to EN initiation (K Chang, MS, RDN, oral
communication, Oct. 2014).
9) What are the specialized nutrient recommendations for the enteral nutritional formula
administered to burn and trauma patients per ASPEN/SCCM guidelines?
Burn and trauma patients have a variety of specialized nutrient recommendations due to the significant
metabolic changes that occur in a critically ill patient. The ASPEN guidelines give clinicians recommendations
to follow regarding certain nutrients. Section A7, part C of the ASPEN guidelines explains the dosage of enteral
nutrition.15 First, energy requirements should be determined at the start of nutrition therapy. Energy
requirements can be determined by a using a predictive equation or through the use of indirect calorimetry.
The calories from the infusion of propofol should be considered in the total amount of calories. Due to the fact
that it is often difficult to obtain 100% of calories via EN, it is recommended that in the first week of
hospitalization, a patient should receive greater than 50-65% of total calorie recommendation.15 If the patient
is still unable to meet calorie recommendations after 7-10 days, part C3 of guideline A7 suggests the initiation
of supplemental parenteral nutrition.15
Similarly, after this 7-10 day period the increased protein recommendations must be met. If the patient
is unable to require enough protein, a common practice is the use of protein supplements. For patients who
have a BMI less than 30, the protein requirements should be about 1.2-2.0 g/kg, but in burn and multi-trauma
patients this range is likely to be higher. The assessment of adequate protein intake is vital in critically ill
7

MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

patients because of the role protein has in wound healing, immune functions, and maintaining leas body mass.
Unfortunately, this assessment is challenging because serum protein markers such as albumin, prealbumin,
transferrin and C-reactive proteins are not valid indicators for the provision of protein.15
In regards to lipid intake, it is suggested to limit total energy from fat to less than 35% of total energy
intake. A few studies show that burn patients can be sensitive to high lipid intakes, specifically with respect to
length of hospital stay and high infection rates.7 At least a small amount of fat is nevertheless required to
prevent any essential fatty acid deficiencies.
In trauma or burn patients and other appropriate situations, immune-modulating enteral formulations
are often implemented. These formulations have a variety of agents including arginine, glutamine, nucleic acid
and antioxidants. In addition, soluble fiber-containing or small peptide formulations may be utilized if diarrhea
becomes a problem.15
10) What additional micronutrients will need supplementation in burn therapy? What dosages are
recommended?
There are many additional micronutrients that are needed for burn therapy. First, an increase of vitamin
C to 250-1,000 mg is recommended. This increase is because of its role in collagen synthesis and wound
repair. One mineral that is also suggested to increase after a severe burn is zinc. Zinc should increase to two
or three times the RDA. This would result in a female zinc requirement of about 24-36 mg/day and a female
zinc requirement of about 30-45 mg/day. The reason for this is because zinc is very important in wound healing
and protein metabolism. In addition, 20% of the bodys store of zinc is in the skin so a burn patient would have
decreased levels of zinc.16 Another vitamin increase is the increase of vitamin A to 8,000-10,000 IU/day.17 In
addition, there has been a recommended increase of magnesium because of wound and urinary losses from
burns and an increase in copper and manganese to maintain nitrogen equilibrium. Increased requirements of
nicotinic acid, biotin, pyridoxine, thiamine and folate are also suggested in terms of improving and healing from
a burn. In general, there is a higher calorie need and because of this, most trauma and burn patients will
receive a higher amount of sodium, potassium, calcium, magnesium, chloride, and phosphorus upon request.16

III: Nutrition Assessment

11) Using Mr. Angelos height and admit weight, calculate IBW, %IBW, BMI, and BSA (body surface
area). (Height = 72 = 182.9 cm; weight = 157# = 71.2 kg)
The following calculations were made using Mr. Angelo's height and admit weight:
IBW (Hamwi Method) = 178# = 80.7 kg [106 + (12 x 6)]
%IBW = 88%, mild malnutrition [(157/178) x 100]
BMI = 21.3, normal [71.2/(1.829*1.829)]
BSA (Mosteller Method)18,19 = 1.9 m2 [SQRT ((182.9 x 71.2)/3600)]
12) Energy requirements can be estimated using a variety of equations. The Xie and Zawacki
equations are frequently used. Estimate Mr. Angelos energy needs using these equations. How
many kcal/kg does he require based on these equations?

MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

Using the Xie equation, we calculated Mr. Angelos caloric requirement to be approximately 2,900
kcal/day or 40.7 kcal/kg/day.20 Using the Zawacki equation, we calculated Mr. Angelos caloric requirement to
be approximately 2,736 kcal/day or 38.4 kcal/kg/day.21
Calculations of Estimated Energy Needs:
Xie Equation: Energy expenditure (kcal/d) = (1000 kcal x BSA [m2]) + (25 x %BSAB)
kcal = (1000 x 1.9) + (25 x 40) = 2,900 kcal/day
2,900 kcal/day / 71.2 kg = 40.7 kcal/kg/day
Zawacki Equation: kcal = (1440 kcal/m2/day) = 2,736 kcal/day
2,736 kcal/day / 71.2 kg = 38.4 kcal/kg/day
13) Determine Mr. Angelos protein requirements. Provide the rationale for your estimate.
The protein needs of burned patients are elevated due to significant losses through urine and the
critical role that protein plays in gluconeogenesis and wound healing. The most recent research suggests that
the protein requirement should provide 20-25% of total calories.1,3 Using the caloric needs estimated with the
Xie equation in Question 12 above, Mr. Angelos protein requirements are 580-725 kcal/day, 145-181 g/day, or
2-2.5 g/kg/day.
The Nutrition Care Manual recommends that a patient with burns on more than 20% TBSA should be
provided a minimum of 1.5-2.0 g/kg.1 Based on this guideline, Mr. Angelos requires at least 107 g protein/day.
Our estimated protein requirement of 145-181 g protein/day for Mr. Angelo based on recommended caloric
intake is consistent with this guideline. Additionally, this high estimate of protein need accounts for the fact that
a large proportion of his body is burned (40% BSAB) and that he is still undergoing debridement and skin
grafting procedures.
14) ***SKIPPED per instructor guidelines***
15) This patient is receiving the medication propofol. Using the information that you listed in
Question 6, what changes will you make to your nutritional regimen and how will you assess
tolerance to this medication?
Propofol is administered in a 10% soybean oil solution (B Cochran, MS, RDN, oral communication,
Nov. 2014). Thus, the amount of calories from fat present in the drug should be subtracted from the
determined EN requirements. In this casebased on continuous IV administration of propofol at a rate of 25
mL/hrwe estimate that Mr. Angelo's TF order would need to be adjusted to provide 660 fewer calories per
day than he is estimated to need. We will not, however, recommend this adjustment in our ADIME note
because the MD progress note indicated that Mr. Angelo was being weaned off of propofol, potentially by the
end of that day. Recommendations for monitoring tolerance to propofol include assessing TG, lipid panel,
serum turbidity, and vital signs.10
Calculations of calories provided by lipids from propofol administration:
***We are using the most recent information from the case study that the patient is being administered
propofol at 25 mL/hr in 10% lipid solution via continuous IV
Total calories from propofol administration = 25 mL/hr x 24 hrs/day x 1.1 kcal/mL = 660 kcal/day

MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

IV: Nutrition Diagnosis

16) Identify at least 2 of the most pertinent nutrition problems and the corresponding nutrition
diagnoses.
Mr. Angelo has significantly elevated calorie, protein, fluid, and other nutrient needs due to thermal
burns covering a large proportion of his body (40% TBSA) and ongoing debridement and skin grafting
procedures. As evidenced by analysis of his 24-hour I/O record (SEE Question 19), the enteral nutrition
he currently receives is dangerously short of meeting his needs at only 25% of caloric needs and 2430% of protein needs. Moreover, his current TF Rx would only meet about half of his EEN even if the
goal rate were achieved (SEE Question 18). In addition to his critical condition following burn trauma, it
is especially important for this patient to receive adequate nutrition as soon as possible because his
weight at admission was indicative of mild malnutrition (88% IBW). Using diagnostic terminology, his
nutrition diagnoses would be inadequate protein-energy intake (NI-5.3); inadequate enteral nutrition
infusion (NI-2.3); increased nutrient needs (NC 5.1)(protein and energy); increased fluid needs (NI-5.1);
increased nutrient needs (NI-5.1)(glutamine, vitamin C, vitamin A, Cu, Se, and Zn); and malnutrition
(NI-5.2)
17) Write your PES statement for each nutrition problem.
Inadequate protein-energy intake (NI-5.3) r/t inadequate EN infusion AEB 24-hr I/O record showing pt
only received ~25% of estimated caloric needs and ~24-30% of estimated protein needs.
Inadequate enteral nutrition infusion (NI-2.3 10641) r/t inappropriate TF Rx and increased demand for
wound healing AEB 24-hr I/O record showing pt only received ~25% of EEN and calculations showing that full
delivery of the current TF Rx would still only meet ~54% of EEN.
Increased fluid needs (NI-5.1) r/t skin loss 2' to burn injuries AEB 40% TBSA burned and oliguria and
hypotension per latest MD progress note.
Increased nutrient needs (NI-5.1)(glutamine, vitamin C, vitamin A, Cu, Se, Zn) r/t increased nutrient
needs to support hypermetabolism and healing s/p extensive burn injuries AEB 40% BSAB and increased
EEN.

V: Nutrition Intervention
18) The patient is receiving enteral feeding using Impact with Glutamine @ 60 mL/hr. Determine the
energy and protein provided by this prescription. Provide guidelines to meet the patients
calculated needs using the Xie equation. Adjust TF orders as you feel clinically appropriate (per
instructor guidelines).
The current tube feeding prescription of Impact with Glutamine @ 60 mL/hr does not specify a goal
number of hours for EN delivery. Since the patient is in critical condition with elevated nutrition needs, we felt it
was logical to assume continuous EN delivery across 20 hrs/day for our calculations. Our calculations show
that the patients current prescription delivered for 20 hrs/day would only meet about 54% of calculated caloric
needs and 52-65% of calculated protein needs. Our specific calculations as well as a summary table of our
findings can be found below.
10

MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

Based on these calculations, the current TF prescription is clearly insufficient to meet patient needs.
Therefore, we recommend the below adjustments to the TF order in order to fully meet the patients nutritional
needs during this critical period. Together, this prescription is expected to provide Mr. Angelo with
approximately 3,000 kcal and 145 g protein per day to meet EEN.
Continuous TF, Vital 1.5 goal 96.6 mL/hr x 20 hrs/day to provide:
1.933 mL EN formula
2,900 kcal
130.4 g protein
33% kcal from fat (<35% kcal from fat)
1,477 mL free water
Pro-Stat Sugar Free 64 modular, 2 tbsp daily to provide:
15 g protein
72 kcal
Sympt-X GI modular, 1/2 pkt BID to provide:
10 g L-glutamine
60 kcal
Table 4
Comparison of nutrition provided by patients current TF order to calculated requirements
NUTRITIONAL
NEEDS

RECOMMENDATION

CURRENT TF RX

EVALUATION

Energy

2,900 kcal/day

1,560 kcal/day

Current TF Rx is not sufficient to

meet energy needs. Current Rx only
provides 54% of pts recommended
caloric intake and TF order should
be adjusted to provide more
calories.

Protein

145-181 g/day

93.6 g/day

Current TF Rx is not sufficient to

meet protein needs. Current Rx only
provides 52-65% of pts
recommended protein intake and TF
order should be adjusted to provide
more protein.

Calculations of Nutrition Provided by Current TF Rx vs. Calculated Needs:22

Total volume of Impact with Glutamine = 60 mL/hr x 20 hr/day = 1,200 mL/day = 1.2 L/day
Total calories = 1.3 kcal/mL x 1,200 mL/day = 1,560 kcal/day
Total protein = 78 g protein/L x 1.2 L/day = 93.6 g protein/day
Calories from current TF Rx / calculated needs: 1,560/2,900 = 54%
Protein from current TF Rx / calculated needs: 93.6/181 = 52%; 93.6/145 = 65%

11

MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

19) By using the information on the intake/output record, determine the energy and protein
provided during this time period. Compare the energy and protein provided by the enteral
feeding to your estimation of Mr. Angelos needs.
Based on the patients 24-hr intake/output record, current provision of enteral nutrition is dangerously
insufficient in meeting the patients needs. Our calculations show that the patients current daily intake of 565
mL of Impact with Glutamine only meets about 25% of calculated caloric needs and 24-30% of calculated
protein needs. Our specific calculations as well as a summary table of our findings can be found below.
Table 5
Comparison of patients actual intake to calculated requirements
NUTRITIONAL
NEEDS

RECOMMENDATION

PATIENTS INTAKE
(24-HR I/O RECORD)

EVALUATION

Energy

2,900 kcal/day

735 kcal

Energy needs are not being met.

Patient is only consuming 25% of
his recommended caloric intake
and TF order should be adjusted to
provide more calories.

Protein

145-181 g/day

44.1 g

Protein needs are not being met.

Patient is only consuming 24-30%
of his recommended protein intake
and TF order should be adjusted to
provide more protein.

Calculations of Actual Intake (24-hr I/O) vs. Calculated Needs:

Total calories = 1.3 kcal/mL x 565 mL/day = 735 kcal
Total protein = 78 g protein/L x 0.565 L/day = 44.1 g protein
Calories from actual intake / calculated needs: 735/2,900 = 54%
Protein from actual intake / calculated needs: 44.1/181 = 24%; 44.1/145 = 30%
20) One of the residents on the medical team asks you if he should stop the enteral feeding
because the patients blood pressure has been unstable. What recommendations can you make
to the patients critical care team regarding tube feeding and hemodynamic status?
Tube feeding should be stopped if the patient becomes hemodynamically unstable.3 Patients with
unstable blood pressure and flow have more difficulty with microcirculation in the intestines. Since the
intestines are struggling to receive adequate blood flow, the patient is at a higher risk for ischemia-reperfusion
injury.15 This injury occurs when there is a lack of blood flow to intestines and, therefore, not enough oxygen
for the organ to function properly to meet increased needs during digestion and absorption. Reperfusion occurs
when the blood flow returns to the intestines. Ideally, this would restore the organ back to its original state;
however, this restoration can result in more organ damage.1 The recommendation that enteral feeding should
be stopped is due to the impairment of the intestines and the increased risk of injury caused by hemodynamic
instability.23

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MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

VI: Nutrition Monitoring and Evaluation

21) List factors that you would monitor to assess the tolerance to and adequacy of nutrition
support.
SEE the Monitoring & Evaluation section of our ADIME note (Question 23).
22) What is the best method to assess calorie needs in critically ill patients? What are the factors
that need to be considered before the test is ordered?
Assessing caloric needs in critically ill patients is often one of the biggest challenges because the
amount of caloric intake among critically ill patients is a very debatable matter. For example, some studies
have proven that intentional caloric underfeeding during the early acute phase could possibly be more
beneficial than full feeding.24 Other research shows that increasing calories through a combination of
parenteral and enteral route is most beneficial. The ESPEN guidelines give general recommendations
regarding how calorie intake should be determined.7 Enteral nutrition therapy must be modified according to
gut tolerance and the progression of the disease. During the initial phase of a critical illness, a general aim
should be to provide about 25-30 kcal/kg/day. In order to decrease negative energy balance it is vital to stay as
close as possible to the measured energy expenditure during this acute recovery phase. Energy needs can be
calculated using predictive equations or measured by indirect calorimetry (IC). One study in particular stated
that the current gold standard is the doubly labeled water method; however, there are many different methods
and each method has its own drawbacks and level of complexity.24 Some methods use anthropometrical data
and other variables in predictive equations such as the Harris-Benedict formula, Penn State equation, and the
equation from Faisy et al. Direct calorimetry is another method, and it measures energy expenditure through
the production of heat by the metabolic process. Due to the fact that this type of method is impossible to do at
bedside, an IC method was created by using concentrations of carbon dioxide and oxygen to calculate energy
expenditure and the respiratory quotient.
There are also a number of factors that need to be considered before deciding which method to use.
First, the patient could be receiving nutrition continuously. Body temperature could be modified by the illness
causing a fever or shivering, which could alter calorie recommendations. Another circumstance that could play
a role in energy expenditure is different types of treatments such as sedative agents or therapeutic
hypothermia.24 As always, certain anthropometric data such as body weight, BMI and %IBW should also be
taken into account. Finally, ventilation and intubation can also impact energy needs.
Currently, it seems that there is no exact right or wrong answer when it comes to which method is best
to assess calorie needs in critically ill patients. The best method will be different for each scenario, so it will be
necessary for clinicians to use their best judgment.
23) Write an ADIME note that provides your nutritional assessment and enteral feeding
recommendation and/or evaluation of the current enteral feeding orders.
SEE the ADIME note on the following page. Since the MD progress note indicated that the patient was
being weaned off of propofol, potentially by the end of that day, we felt it was best not to account for calories
from lipids used in delivery of propofol when adjusting the TF order.

13

MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

Nutrition Care

Progress Note

ASSESSMENT

DIAGNOSIS

INTERVENTION

MONITORING & EVALUATION

65 y.o M w/ a level 2 trauma with 40%

BSAB consisting of 1st to 3rd degree on
his face, umbilicus, back, buttocks,
abdomen, upper/lower extremities, and
genitalia; PMH and Dx's of: DM, HTN,
GERD, s/p cholecystectomy, and smoking
1 PPD; pt sedated and intubated

Inadequate protein-energy
intake (NI-5.3) r/t inadequate
EN infusion AEB 24-hr I/O
record showing pt only
received ~25% of estimated
caloric needs and ~24-30%
of estimated protein needs.

Adjust TF Rx (ND-2.1) to the

following: Continuous TF, Vital 1.5
goal 96.6 mL/hr x 20 hrs/day to
provide ~1,933 mL formula, 2,900
kcal, 130.4 g protein, 1,477 mL free
water, and 33% kcal from fat per day.

Monitor I/O intake to assess

progression of EN infusion toward
intake goals of ~2,900 kcal, 145-181
g protein, and 2,900 mL fluid per
day. If pt is unable to reach at least
50-65% of intake goals within 7-10
days, consider PN supplementation.

Skin: Beefy red to pale color; cool and

moist; poor turgor; weeping; sloughing;
ruptured blisters; and necrosis
Throat: Dry mucous membranes,
presence of soot in nares and oropharynx
Abdomen/GI: Distended, soft w/ hypo BS

Inadequate enteral nutrition

infusion (NI-2.3) r/t
inappropriate TF Rx and
increased demand for wound
healing AEB 24-hr I/O record
showing pt only received
~25% of EEN and
calculations showing that full
delivery of the current TF Rx
would still only meet ~54% of
EEN.

Meds: Ascorbic acid, chlorhexidine,

famotidine, heparin, insulin, MVI, zinc
sulfate, methadone, oxandrolone, senna,
docusate, silver sulfadiazine,
acetaminophen prn, midazolam HCl
(versed), hydromorphone (dilaudid),
fentanyl (sublimaze), thiamin, folate; and
propofol (diprivan); currently being
weaned off of propofol per MD
Labs (abnormal):
K 5.9 mEq/L
Cl 113 mEq/L
CO2 20 mEq/L
Cr serum 1.26 mg/dL
Glucose 211 mg/dL
Mg 1.5 mg/dL
Ca 6.9 mg/dL
Protein 4.7 g/dL
AST 44 U/L
CRP 12 mg/dL
3
3
WBC 18.1 x 10 /mm

Increased fluid needs (NI5.1) r/t skin loss 2' to burn

injuries AEB 40% TBSA
burned and oliguria and
hypotension per latest MD
progress note.

DATE & TIME: 11/18/2014 08:00

Supplement Vital 1.5 formula with

Pro-Stat Sugar Free 64 modular
(ND-2.1). Add 2 tbsp daily to provide
an additional 15 g protein and 72 kcal
per day to help meet EEN.
Supplement Vital 1.5 formula with
Sympt-X GI modular (ND-2.1). Add
1/2 pkt BID to provide an additional
10 g L-glutamine and 60 kcal per day
to promote healing and help meet
EEN.
Collaborate with other providers
(RC-1.4) to ensure EN infusion rate is
advanced 20 mL/hr q 4 hrs toward
96.6 mL/hr goal and that TF is only
held when necessary (ND-2.1).
Collaborate with other providers
(RC-1.4) to ensure pt is meeting fluid
intake goal of ~2,900 mL/day and
maintaining proper hydration status
via a combination of IVF and 3-6 free
water feeding tube flushes per day
with details to be managed by the
medical team (ND-2.2.7; ND-2.1.9)

Monitor weight, nitrogen balance,

wound healing, and development of
pressure sores to assess the
adequacy of EN support.
Monitor for proper tube placement
and patency, S/S of aspiration;
hydration status; glycemic status;
hemodynamic instability; fever;
infection; altered GI function (N/V/D,
constipation, abdominal
pain/distension, flatus, constipation,
and/or irregular stools); and
mechanical complications (tube
occlusion or tissue irritation) to
assess pts tolerance to EN support.
Pay particular attention to S/S
aspiration, glycemic status, and
hemodynamic stability due to pt hx
of GERD, DM, and HTN.

14

MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

Hgb 18.7 g/dL

Hct 54.4%
(Decreased Alb/PAB levels were omitted
because these drop in response to acute
stress and thus are not currently reliable
indicators of nutritional status in this pt)
Diet: NPO w/ EN; TF Rx: Continuous TF,
Impact w/ Glutamine 60 mL/hr goal);
recent 24-hr I/O record indicated EN
intake of 565 mL providing 735 kcal and
44.1 g protein
Allergies: Acetaminophen; NKFA
Chewing/Swallowing: Currently unable
to bite/chew/swallow 2' to sedation and
intubation to protect airway

Wt: 157# (71.2 kg)

Ht: 72 (182.9 cm)
IBW: 178# (80.7 kg)
%IBW: 88% (mild malnutrition)
BMI: 21.3 (normal)
2
BSA: 1.9 m
EEN: 2,900 kcals/day (Xie equation)
145-181 g/day (20-25% kcal)
Fluid: 2,900 ml/day (1 mL/kcal/day)

Signature & Credential: Alainna Baxley, Kelsey Conyers, Xiaolu Hou, and Sarah Liu, (future) RDNs

15

MNT Case Study 2: Nutrition Support in Burn Injury

Group 9: Pumpkins

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