Influence of enteral nutrition on the frequency of complications in case of major burns

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1 957 Influence of enteral nutrition on the frequency of complications in case of major burns Daiva Gudavičienė, Rytis Rimdeika, Kęstutis Adamonis 1 Division of Plastic Surgery and Burns, 1 Clinic of Gastroenterology, Kaunas University of Medicine Hospital, Lithuania Key words: burns, enteral nutrition, mortality, sepsis, pneumonia. Summary. The objective of the study was to assess if enteral nutrition reduces the rate of severe complications and complication-related mortality in case of major burns. Material and methods. Two groups were included in the study. Group A was assessed prospectively and included 67 patients treated in Kaunas University of Medicine Hospital in These patients received kcal/kg/day in enteral way over the period of wound surgery. Group A was compared with Group B, which was assessed retrospectively and included 71 patients without enteral nutrition treated in Groups were homogeneous by patients age; extent of general and deep burn area; Baux and Burn indexes. Results. 10 patients (15%) in Group A had pneumonia, 3 (30%) of them died; 11 (16%) had lung edema, 3 (27%) of them died; 24 (36%) had sepsis, 3 (12.5%) of them died; renal insufficiency was diagnosed to 4 patients (6%) in Group A, 2 (50%) of them died. In Group B (without enteral nutrition) pneumonia was diagnosed to 27 patients (38%) of 71, 18 (63%) of them died; lung edema to 20 (28%), 18 (90%) of them died, 19 patients (27%) had sepsis, 12 (63%) of them died; renal insufficiency was diagnosed to 10 patients (14%), all of them (100%) died. Conclusions. Enteral nutrition statistically significantly diminished frequency of pneumonia and lung edema for burned patients. Pneumonia, lung edema, sepsis and renal insufficiency were less hazardous for life of patients with enteral nutrition (p<0.05). Introduction In the latest years the average annual number of burns in Lithuania was 2.6 burns per 1000 inhabitants. The total average number of patients with burns in the last decade was 9740 per year. Despite a small decrease in number of total burns, number of patients who underwent hospital treatment increased from 15.8% in 1993 to 22.4% in The reason undoubtedly was the increased number of patients with severe burns (1). In the period there were patients with burns annually treated in the Department of Plastic Surgery and Burns of Kaunas University of Medicine Hospital (KUMH), on average 216 patients per year (standard deviation (SD) 19.89). The majority of patients (87.6%) treated in KUMH had deep burns. The total extent of burns decreased from 12.7% of body surface area burned (BSAB) in 1981 to 10.99% in 2001, however the area of deep burns increased. Notwithstanding the almost halved hospital-stay time in the period , it is still long enough 26.6 days (2). The mortality due to burns varied from 6 to 12% in the period in the Center of Burns, KUMH (3) and was from 9 to 22% in the period (mean 15%, SD 6.4). Up to the year 1998 organisms reserves of patients with major burns were sustained with repeated infusions of refrigerated plasma and albumin; very seldom in the presence of very severe burns nutrient supplements were administered. In our opinion such kind of metabolic treatment could not ensure satisfying patients needs of energy and nutrients. It could also influence the rate of complications developed and the treatment results obtained. In 1999 the use of manufactured mixtures was initiated for enteral nutrition of burned patients in KUMH. We agree with an amount of energy that is being recommended by the specialists of nutrition in the latest years for patients with major traumas i. e kcal/kg/day (4) such amount of energy received in enteral way patients are able to tolerate and to assimilate. Considering that for many burned patients it is possible to eat per os, we assume that this amount of energy is enough over the period of wound Correspondence to D. Gudavičienė, Division of Plastic Surgery and Burns, Kaunas University of Medicine Hospital, Eivenių 2, Kaunas, Lithuania. daikle@centras.lt

2 958 Daiva Gudavičienė, Rytis Rimdeika, Kęstutis Adamonis surgery. There have not been any studies conducted or articles published in Lithuania on the subject of influence of burned patients enteral nutrition to the frequency of developing complications. The thematic information concerning the burned patients nutrition of the past 20 years was analyzed in MEDLINE and COCHRANE databases. There were many articles found concerning the proportions of main nutrients (proteins, lipids, carbohydrates), other nutrients (arginine, omega-3, omega-6 fatty acids), the influence of different ways of nutrition (enteral and parenteral) to the mortality and complications rate for burned patients. However studies, which would compare the complications rate and complication-related mortality for patients receiving enteral nutrition to the patients without enteral nutrition have not been found. However, it is fully understandable it would not be ethical to conduct such study prospectively to administer proper nutrition to one group and not to another. Therefore we decided that it is a matter of great relevance to conduct the study and analyze the efficiency of enteral nutrition for patients with major burns and to find out if it diminishes complications (pneumonia, lung edema, sepsis, renal insufficiency) rate; if the complications are equally dangerous to life with sufficient enteral nutrition and without enteral nutrition. Material and methods The study included year old patients with 10 80% BSAB, without the airways burns and without any severe decompensated adjacent diseases. The patients who had early escharectomies and skin grafting were not included in this study because the changes in surgical techniques during the past 5 years could have influenced the results. The prospective study has been conducted in the period of After the need of energy has been counted (30 40 kcal/kg/day) according patient s weight, the nutrition plan has been decided. The mixtures of normal caloric content (1 ml 1 kcal) or high caloric content (1 ml 1.5 kcal) have been administered. Having patient s agreement the nasogastric or nasoduodenal tube was inserted as soon as possible following the hospitalization. During the wound surgery period the amount of calories per day was registered. In case of receiving kcal/kg/day the patient was put to the Group A. If nutrition was insufficient, patients were excluded from the study. There were 110 patients studied in prospective study 89 of them had sufficient enteral nutrition. After excluding the patient who had early escharectomies and skin grafting there were 67 patients left in enteral nutrition group (Group A). Retrospective study (Group B) included 71 patients treated in the period This group was identical to the Group A according to patients age; extent of general and deep burn area (p>0.05). For the evaluation of prognosis the Burn indexes suggested by W. Baux (in 1962) as well as J. P. Bull and A. J. Fischer (1954) were used. The Baux index is the sum of patient s age and the percentage of the BSAB. The counting is easy but it does not evaluate the depth of a burn therefore the index modified by USA Brooke military medicals A. Schwartz and colleagues where the percent of deep burn is considered as a point, and the percent of the superficial burn is considered as half of a point. It also refers to the age of a patient (5). These indexes were used to standardize the groups. The groups were homogeneous in accordance with W. Baux as well as J. P. Bull and A. J. Fischer Burn s indexes (p>0.05). The frequency of pneumonia, lung edema, sepsis, renal insufficiency and mortality of patients with these complications were studied in the groups. Pneumonia and lung edema were diagnosed according to clinical symptoms, findings in X-ray examinations and conclusions of therapeutist; sepsis according to clinical symptoms after the confirmation of microorganisms growth in blood culture; renal insufficiency according to laboratory tests. Complication-related mortality was examined in both groups. Results are shown as mean and standard deviation (SD). Statistical analysis was performed using STATIS- TICA 5.0 program. As distribution of studied variables was not normal (Shapiro-Wilk test), nonparametric statistics was used. For comparison of categorical values Mann-Whitney test was used. For comparison of quantitative values χ² test was used. Error probability p<0.05 was considered to be sufficient. Results The patients age was (SD 16.04) years in Group A and (SD 13.80) years in Group B. There was no statistically significant difference among the age of patients in two groups (p 0.32). General burn area was % (SD 17.27) in group A and % (SD 15.86) in Group B. Deep burn area was % (SD 12.10) in Group A and % (SD 13.96) in Group B. Both groups were homogeneous according to general (p 0.38) and deep burn area (p 0.06). Groups were standardized according to Baux and Burn indexes. There was no statistically significant difference among the age, general and deep burn area of patients in two groups. Probability of

3 Influence of enteral nutrition on the frequency of complications in case of major burns 959 Table 1. Patients age, general and deep burn area and Burn s indexes Characteristic Group A Group B p Age, in years (SD 16.04) (SD ) 0.32 General burn area, in % (SD 17.27) (SD 15.86) 0.38 Deep burn area, in % (SD 12.10) (SD 13.96) 0.06 Index of Baux (SD 20.54) (SD 19.47) 0.90 Burn s index (SD 30.98) (SD 32.11) 0.64 patients to survive in both groups did not differ (p>0.05). Table 1 shows the patients characteristics in groups. The frequency of developed complications in both groups is shown in Table 2. In the group with enteral nutrition statistically significantly less cases of pneumonia (10 (15%) in Group A versus 27 (38%) in Group B) and lung edema (11 (16%) versus 20 (28%)) were observed The difference of the frequency of sepsis (24 (36%) versus 19 (27%)) and renal insufficiency (4 (6%) versus 10 (14%)) between groups A and B was not statistically significant. Thirty percent of patients who had pneumonia died in Group A versus 63% in Group B, in case of lung edema 27% versus 90%, sepsis 12.5% versus 63% and renal insufficiency 50% versus 100%. It can be clearly seen in Table 3, that all complications in group without enteral nutrition resulted in higher mortality than in group with enteral nutrition. Discussion After retrospective analysis of causes of death of burned patients in KMUH in 2002 it was found that 37% died because of lung edema, 54% pneumonia, 37% sepsis, and 51% renal insufficiency (6). Thematic search in MEDLINE and COCHRANE medical databases resulted in many studies on the subject of complications frequency and complicationrelated mortality in burned patients found. According to the records of medical doctors from Turkey (R. Anlatici), 33.5% of 1083 treated patients died; 47.1% of them died because of sepsis and multiple organ insufficiency; 44.6% renal insufficiency; 5.8% respiratory insufficiency; and 2.5% because of bleeding in gastrointestinal tract (7). According to our data there were no deaths due to bleeding in gastrointestinal tract while using H-2 blockers for prevention of ulcers. J. Firzwater (USA, 2003) published a prospective study of 175 patients with 20% BSAB where mor- Table 2. The frequency of developed complications Complication Group A, n=67 Group B, n=71 p Pneumonia 10 (15%) 27 (38%) 0.041* Lung edema 11 (16%) 20 (28%) 0.028* Sepsis 24 (36%) 19 (27%) Renal insufficiency 4 (6%) 10 (14%) * The difference is statistically significant. Complication Table 3. Complication-related mortality Group A, Group A Group B, Group B died died in % died died in % Pneumonia 3/ / * Lung edema 3/ / * Sepsis 3/ / * Renal insufficiency 2/ / * * The difference is statistically significant. p

4 960 Daiva Gudavičienė, Rytis Rimdeika, Kęstutis Adamonis tality was 22%; 27% of these patients had multiple organ insufficiency, 17% sepsis (8). There were more cases of sepsis in our study in 36% patients with enteral nutrition and in 27% without enteral nutrition. In the study by R. L. Bang (Kuwait) there were 943 patients examined; 28.8% of them developed sepsis. The mortality of patients with sepsis was 29.1%. According to our data, a similar frequency of sepsis was recorded: 12.5% of patients with diagnosed sepsis in enterally nourished group and 63% in enterally not nourished group have died. R. L. Bang connects this low mortality level in his department (29.1%) with timely diagnosed septicemia and effective antibiotic therapy, early sufficient enteral nutrition and early necrosis excision as well as wound coating (9). We achieved abundantly lower mortality of patients with diagnosed sepsis in the group with enteral nutrition 12.5% versus 63% in not nourished group, p The digestive tract is a very vulnerable place of burn victims. Studies with animals have proven that early enteral nutrition with glutamine and fibers diminishes bacterial translocation in the intestine and mortality related with that (10). D. A. De Souza (1998, Brasilia) indicates that metabolism increased due to burns causes immune system deficiency and this diminishes wound healing and impairs healing quality, predisposes more frequent infectious complications, prolongs hospital stay time and increases patients mortality. It is recommended to commence enteral nutrition with immunomodulators (arginine, glutamine) for prevention of immune system deficiency (11). However, there are publications where authors discuss and doubt whether enteral nutrition diminishes mortality, complication rate and hospital stay time for patients with major burns, e. g. D. W. Wilmore (1997, USA) states that only the efficiency of total parenteral nutrition with glutamine is definitely proven for curing burn victims, and efficiency of enteral nutrition is not proved (12). Therefore the question about enteral nutrition of patients with heavy burns remains in discussion, requiring evidence, when comparing groups with and without enteral nutrition. We were not successful in finding studies that would compare frequency of complications for patients with and without enteral nutrition. This is understandable, as to make a prospective study of such kind to nurture one group and the other one not to would be unethical. Therefore we compared two groups: prospective (enterally nourished) and retrospective (without enteral nutrition). With this study we proved efficiency of sufficient enteral nutrition in major burns pneumonia and lung edema was statistically significantly more seldom in enteral nutrition group; in all complications: pneumonia, lung edema, sepsis and renal function insufficiency complicationrelated mortality was lower in enteral nutrition group compared with a group without enteral nutrition. In 2002 D. W. Hart s study was published, which studied 250 survivors with 10 99% BSAB. It turned out that patients mortality was statistically significantly higher, sepsis more frequent if required energy level was with nutrition not insured (energy need was estimated with indirect calorimetry) (13). These results coincide with our data achieved and let us conclude that sufficient enteral nutrition diminishes mortality of patients cured of major burns. Canadian scientists published an article about peculiarity of nutrition of burned patients in All randomized controlled studies and meta-analyses about nutrition of burned patients are published in MEDLINE, CINAHL (cumulative index to nursing and allied health), EMBASE, Cochrane Library till 2002 were analyzed. After summarizing, the conclusions was made that the first choice method is enteral nutrition. Only if enteral nutrition is impossible parenteral nutrition is recommended. It is recommended to commence nutrition during the first 48 hours after hospitalization (14). Conclusions Enteral nutrition statistically significantly diminishes the rate of pneumonia and lung edema for heavily burned patients. Enteral nutrition statistically significantly diminishes complication-related mortality of patients with such complications, as pneumonia, lung edema, sepsis, renal insufficiency. Enterinio maitinimo įtaka didelių nudegimo traumų komplikacijų dažniui Daiva Gudavičienė, Rytis Rimdeika, Kęstutis Adamonis 1 Kauno medicinos universiteto klinikų Plastinės chirurgijos ir nudegimų skyrius, 1 Gastroenterologijos klinika Raktažodžiai: nudegimai, enterinis maitinimas, mirštamumas, sepsis, pneumonija.

5 Influence of enteral nutrition on the frequency of complications in case of major burns 961 Santrauka. Tikslas. Nustatyti, ar enterinis maitinimas mažina komplikacijų dažnį gydant sunkiai nudegusius ligonius, ar komplikacijos yra mažiau grėsmingos gyvybei lyginant su enteriškai nemaitintais ligoniais. Medžiaga ir metodai. Lygintos dvi pacientų grupės. A grupė sudaryta iš prospektyviai ištirtų 67 pacientų, gydytų Kauno medicinos universiteto klinikų Plastinės chirurgijos ir nudegimų skyriuje m., kurie po operacijų gavo pakankamą enterinį maitinimą kkal/kg per parą. A grupė lyginta su retrospektyviai ištirta B grupe pacientų, gydytų Kauno medicinos universiteto klinikose m. (71 pacientas), kurie nebuvo maitinti enteriškai. Grupės buvo homogeniškos pagal amžių, bendrą ir gilaus nudegimo plotą, Baux ir nudegimo indeksus. Rezultatai. 10 pacientų iš A grupės (67 pacientai, maitinti enteriškai) nustatyta pneumonija (15 proc.), iš jų 3 mirė (30 proc.); 11 pacientų (16 proc.) nustatyta plaučių edema, iš jų mirė 3 (27 proc.); 24 pacientams (36 proc.) nustatytas sepsis, iš jų 3 mirė (12,5 proc.); inkstų funkcijos nepakankamumas diagnozuotas 4 (6 proc.), iš jų 2 (50 proc.) mirė. B grupėje (71 pacientas, nemaitintas enteriškai) pneumonija diagnozuota 27 (38 proc.) pacientams, iš jų 18 (63 proc.) mirė; sepsis nustatytas 19 (27 proc.), iš jų mirė 12 (63 proc.); inkstų funkcijos nepakankamumas nustatytas 10 (14 proc.), visi mirė (100 proc.). Išvados. Enterinis maitinimas statistiškai reiksmingai sumažino pneumonijos ir plaučių edemos dažnį tarp sunkiai nudegusių pacientų. Enteriškai maitintiems pacientams išsivysčiusios komplikacijos: pneumonija, plaučių edema, sepsis, inkstų funkcijos nepakankamumas buvo mažiau pavojingos gyvybei negu enteriškai nemaitintų pacientų grupėje (p<0,05). Adresas susirašinėti: D. Gudavičienė, KMUK Plastinės chirurgijos ir nudegimų skyrius, Eivenių 2, Kaunas El. paštas: daikle@centras.lt References 1. Pundzius J, et al. Nacionalinės sveikatos tarybos metinis pranešimas 2002 m. Lietuvos gyventojų traumos, nelaimingi atsitikimai ir kitos visuomenės sveikatos aktualijos. (Annual report of National Health Council, Traumas, accidents and other actualities of social health.) Vilnius; p Rimdeika R, Jankūnas V, Pilipaitytė L, Mikužis M. Suaugusiųjų nudegimų traumatizmo pokyčiai ir prevencijos kryptys. (Burn trauma alteration and prevention directions in adults.) Sveikatos mokslai 2003;13(1): Rimdeika R. Chirurginių metodų efektyvumas gydant riboto ploto nudegimus. Daktaro disertacija. (Efficiency of surgery methods in curing limited area burns. Doctoral thesis.) Kaunas: Kauno medicinos universitetas; p Sobotka L, Allison SP, Furst P, Meier R, Pertkiewicz M, Soeters PB, et al. Basic in clinical nutrition. 2nd ed. Publishing House Galén; p Rimdeika R. Nudegimų chirurgija. (Burns surgery.) Kaunas: Katechetikos centro leidykla; Klezytė D, Rimdeika R, Grigaitė R. One-year review of causes of burn-related deaths in Kaunas Medical University Hospital. Acta Medica Lituanica 2001; Suppl 7: Anlatici R, Ozerdem OR, Dalay C, Kesiktas s E, Acartürk S, Seydaoglu. A retrospective analysis of 1083 Turkish patients with serious burns. Part 2: burn care, survival and mortality. Burns 2002;28(3): Fitzwater J, Purdue GF, Hunt JL. The risk factors and time course of sepsis and organ dysfunction after burn trauma. J Trauma 2003;54(5): Bang RL, Gang RK, Sanyal SC, Mokaddas E, Ebrahim MK. Burn septicemia: an analysis of 79 patients. Burns 1998;24(4): Zapata-Sirvent RL, Hansbrough JF, Ohara MM, Rice-Asaro M, Nyhan WL. Bacterial translocation in burned mice after administration of various diets including fiber- and glutamineenriched enteral formulas. Crit Care Med 1994;22(4): De-Souza DA, Greene LJ. Pharmacological nutrition after burn injury. J Nutr 1998;128 (5): Wilmore DW. Postoperative protein sparing. World J Surg 1999;23(6): Hart DW, Wolf SE, Herndon DN, Chinkes DL, Lal SO, Obeng MK, et al. Energy expenditure and caloric balance after burn: increased feeding leads to fat rather than lean mass accretion. Ann Surg 2002;235(1): Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 2003;27: Received 17 February 2004, accepted 15 September 2004 Straipsnis gautas , priimtas

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