Cutting-Edge Forward Burn Nutrition: from the Battlefield to the Burn Center

Current Trauma Reports, Apr 2016

The US Army Institute of Surgical Research (USAISR) Burn Center is among the first and largest burn centers in the world and is the only US military burn center. This American Burn Association-verified facility is located on the Fort Sam Houston military base, in San Antonio, TX. It has provided comprehensive burn care to both military personnel and civilians in the South Texas area since the end of World War II. The global mission of the USAISR is to optimize combat casualty care, including care for major thermal injuries. This optimization of combat casualty care is executed clinically in the USAISR Burn Center through interdisciplinary teamwork and by advancing the care provided based on leading edge research. This article focuses on clinical lessons learned in the area of burn nutrition over the last decade at this facility during the support of the combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom; it also provides a review of current evidence-based nutritional medicine practices for treating patients with thermal injuries. The extreme nutritional demand and metabolic changes associated with severe burns have been well described. This hypermetabolic, hypercatabolic response can lead to lean body mass and strength loss, resulting in the lack of ability to perform activities of daily living, as well as infection, wound healing failure, and death. Nutrition is an essential tool to avoid these catastrophic results, but monitoring the nutrition status is complicated by the whole body volume overload, resulting from the initial massive fluid resuscitation, which is required to prevent cardiovascular collapse. Techniques such as estimating weight loss from the caloric deficit must be utilized in place of actual weight loss until the interstitial fluid is reclaimed and a dry weight is achieved. Replenishing the extreme caloric expenditure and nitrogen loss is challenging; hence, careful monitoring of the nutrition intake is an essential component of burn treatment. In addition, there are a number of potential adverse effects of nutritional therapy that must also be factored into the complex decision-making regarding the initiation and delivery of nutrition in the critically ill burn population.

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Cutting-Edge Forward Burn Nutrition: from the Battlefield to the Burn Center

Curr Trauma Rep Cutting-Edge Forward Burn Nutrition: from the Battlefield to the Burn Center Beth A. Shields 0 1 2 3 Booker T. King 0 1 2 3 Evan M. Renz 0 1 2 3 Clinical Case 0 1 2 3 0 Nutritional Medicine & Metabolism, USAISR Burn Center , 3698 Chambers Pass STE B, JBSA FT Sam Houston, Houston, TX 78234-7767 , USA 1 Evan M. Renz 2 Booker T. King 3 Brooke Army Medical Center , 3551 Roger Brooke Drive, JBSA Ft Sam Houston, Houston, TX 78234-7767 , USA The US Army Institute of Surgical Research (USAISR) Burn Center is among the first and largest burn centers in the world and is the only US military burn center. This American Burn Association-verified facility is located on the Fort Sam Houston military base, in San Antonio, TX. It has provided comprehensive burn care to both military personnel and civilians in the South Texas area since the end of World War II. The global mission of the USAISR is to optimize combat casualty care, including care for major thermal injuries. This optimization of combat casualty care is executed clinically in the USAISR Burn Center through interdisciplinary teamwork and by advancing the care provided based on leading edge Nutrition and trauma; Burn nutrition; Thermal injuries; Burn care; Enteral nutrition; Parenteral nutrition; Hypermetabolism - The opinions or assertions contained herein are the private views of the author and are not to be construed as official or as reflecting the views of the Department of the Army or the Department of Defense. This article does not contain any studies with human or animal subjects performed by any of the authors. research. This article focuses on clinical lessons learned in the area of burn nutrition over the last decade at this facility during the support of the combat casualties from Operation Iraqi Freedom and Operation Enduring Freedom; it also provides a review of current evidence-based nutritional medicine practices for treating patients with thermal injuries. The extreme nutritional demand and metabolic changes associated with severe burns have been well described. This hypermetabolic, hypercatabolic response can lead to lean body mass and strength loss, resulting in the lack of ability to perform activities of daily living, as well as infection, wound healing failure, and death. Nutrition is an essential tool to avoid these catastrophic results, but monitoring the nutrition status is complicated by the whole body volume overload, resulting from the initial massive fluid resuscitation, which is required to prevent cardiovascular collapse. Techniques such as estimating weight loss from the caloric deficit must be utilized in place of actual weight loss until the interstitial fluid is reclaimed and a dry weight is achieved. Replenishing the extreme caloric expenditure and nitrogen loss is challenging; hence, careful monitoring of the nutrition intake is an essential component of burn treatment. In addition, there are a number of potential adverse effects of nutritional therapy that must also be factored into the complex decision-making regarding the initiation and delivery of nutrition in the critically ill burn population. A 22-year-old Army soldier was on patrol at a busy market in southern Afghanistan when an Afghani female detonated an explosive vest she was wearing underneath her clothing. Several soldiers were injured, but this soldier received the most severe injuries: 60 % total body surface area (TBSA) burn, partial traumatic amputations of his bilateral lower extremities, a penetrating abdominal injury with evisceration of intra-abdominal contents, and a traumatic brain injury. Tourniquets were placed above the injuries to his lower extremities, a sternal interosseous infusion device was placed, and two liters of crystalloid were infused. The patient was expeditiously transported to a Combat Support Hospital where he was intubated, and central venous and arterial lines were placed. After transfusion of blood products, the fluid resuscitation was started in accordance with the USAISR BRule of Tens^ formula [ 1 ]. He was taken to the operating room where the amputations were completed to his lower extremities (wounds were left open), an exploratory laparotomy was performed with a small bowel resection, and a negative pressure wound device for temporary abdominal coverage was placed. He was transported by the Air Force Critical Care Air Transport Team from Afghanistan to Landstuhl Regional Medical Center in Germany several hours later. The fluid resuscitation was completed shortly after arrival to Germany. In Germany, the lower extremity and abdominal wounds were irrigated, a jejunostomy feeding tube was placed, and the abdomen was closed. The US Army Burn Flight Team changed the burn wound dressings, performed a superficial burn wound debridement, and then transported the patient via military aircraft from Germany to the USAISR Burn Center in San Antonio, TX. Enteral feeding was started via the jejunostomy tube shortly (...truncated)


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Beth A. Shields, Booker T. King, Evan M. Renz. Cutting-Edge Forward Burn Nutrition: from the Battlefield to the Burn Center, Current Trauma Reports, 2016, pp. 106-114, Volume 2, Issue 2, DOI: 10.1007/s40719-016-0044-0