BURN CARE AND PREVENTION JOURNAL

KEY WORDS: Electric burn, Fat loss, Major burn, Muscle loss, Weight loss in burns

Burn-induced severe metabolic derangements (known as burn cachexia) increase morbidity and mortality and interfere with recovery and wound healing in patients who have been burned. Burn cachexia can cause cardiovascular dysfunctions and can impair immune functions, which may render patients susceptible to infection and sepsis.^1-7 Muscle loss in burns at the acute phase is a primary indicator to identify or consider the possibility of cachexia. Rapid weight loss affects the wound healing state of the patient and may lead to sepsis, which may further progress to severe negative complications or mortality. Inflammation-induced protein degradation and increased death of muscle cells are associated with the burn injury response. Several studies have previously reported that early symptoms of significant rapid weight loss and/or anemia and anorexia are commonly observed in patients with major burn, usually within 2 weeks postinjury. Another major contributing factor for burn cachexia is immobilization. Specifically, immobilization inhibits protein synthesis and ultimately affects the healing of burn wounds.^2,4,8-12 Early detection is crucial in cases of burn cachexia, because treatment must be initiated as soon as possible to prevent further catabolism. The standard treatment includes skin grafting or wound closure, good nursing care, and optimum nutrition support, as well as physiotherapy.^13-17 Pharmacological support is recommended to reduce proteolysis and promote protein synthesis via the protein kinase pathway. Strict vital monitoring is suggested during the application of these agents.^18-20 Nutrition support plays a pivotal role in overall recovery and outcome. Close monitoring of nutrition provision contributes substantially to a holistic prevention strategy of burn cachexia management.^21,22

A 20-year-old male patient was admitted with alleged history of 35% total burn surface area from an accidental electric flash burn near the periphery of Indore district. He had been working at the farming site at his village when this incident occurred. Primary treatment was performed at the hospital near his village, and he subsequently arrived at our center on day 14 after the burn injury. He had abstained from solid food for the previous 14 days since the burn injury, and his diet had been restricted to oral liquids. His wounds had subsequently developed infection, and he had experienced substantial weight loss.

Our primary objective was to identify the burn cachexia, nutritional status, and the risk of malnutrition, along with the degree of infection of the burn wound. Our secondary objective for this case included the interventional therapy of burn cachexia and initiation of the nutrition care process, along with close monitoring of nutrition provision.

Management strategies

The initial management at the time of hospitalization was wound dressing and medical management. The burn size was calculated by the method of Lund and Broder. Weight and height were measured on admission before wound dressing. The nutrition care process was initiated immediately after the wound dressing and primary treatment were complete.

Burn cachexia diagnosis

Following factors were considered to diagnose burn cachexia: (1) significant weight loss/muscle loss, (2) anorexia, and (3) extreme fatigue (inability to walk).

Nutrition care process

A 4-step method was performed to complete this care process.
(1) For nutrition assessments, a specialized nutrition assessment tool (based on anthropometry, biochemistry, and clinical and dietary history) was applied at the time of admission. The patient’s height was 183 cm and initial weight was 70 kg, but after day 14 his weight was 50 kg (20 kg weight loss); he had been following an ovo-vegetarian diet regimen.
(2) The nutrition diagnosis was undernourished premorbid nutritional status with poor dietary intake, which was compounded by the acute associated stress of burn injury.
(3) Nutritional calculation was performed according to the Curreri formula = (25 × body weight in kilograms) + (40 × the percent of total burn surface area). Protein requirement was calculated as 1.5 g protein per kilogram body weight with addition of wound protein loss, where wound protein loss = (1.2 × body surface area in square meters) × the percent total burn surface area. Micronutrient supplements were added according to the following fixed protocol: tablet A to Z once daily, vitamin C 500 mg twice daily, and vitamin E 100 mg once daily. A calculated diet plan was prepared as a target goal and was achieved with whey isolate supplementation until the wound was not covered with the skin grafts. Later, when the wound had been covered with the skin grafts, the protein requirement was recalculated and wound protein loss factor was eliminated from the daily requirement. Anabolic steroids were added to control the higher metabolic stress with strict monitoring of heart rate and blood pressure. Supplementation with whey protein isolates has been shown to produce very good results in the healing and recovery of burn wounds, and it also helps to achieve the optimum protein requirement without the need for our patients to consume high-volume meals. One scoop of whey protein isolate (30 g) provides 25 g of high-value biologic protein, which can be easily administered with regular drinking water or coconut water or juices.
(4) Monitoring and reassessment were performed regularly. Daily dietary intake was monitored by the 24-hour diet recall method and included the monitoring of gastrointestinal symptoms such as vomiting, nausea, or loose stools, as well as fever and abdominal distension. Weekly monitoring of weight and wound size was performed with other clinical conditions.

During the total 33 days of hospital stay, our patient’s wound healed well, and only 5% superficial wound remained at the hospital discharge day. Success was reported and characterized as no further weight loss during hospitalization and optimum nutrition delivery through oral intake. Our patient was discharged with a multidisciplinary plan that included a diet chart and counselling, medical management and nursing care at home, and rehabilitation follow-up. The patient had regular follow-up visits once a month, for which diet recall and weight monitoring were performed with clinical check-up.

A limited number of studies have been published on the subject of burn cachexia, and it is generally unidentified and underdiagnosed, which leads to severe consequences if such cases remain untreated in particular scenarios. Surgical graft, medical management, nutrition support, nursing care, and physiotherapy are all important aspects of burn management, and cachexia support with anabolic agents provides crucial benefits to patient recovery and healing. We consider several aspects in cases of burn cachexia, one of which is feeding patients with severe burns who have anorexia. Such cases present a difficult challenge to achieve the goal of optimum nutrition support for healing and recovery of wounds while avoiding the need for high-volume food intake by the patients. For these cases, the dietician plays a vital role to plan a diet with adequate calories and protein while maintaining low volume and high density, with appropriate consideration of other possible associated complications, as well as careful monitoring.

Early detection of burn cachexia facilitates prevention of further weight loss and serves as a guide to provide correct nutrition support. Presently, in most cases, patients with major burns remain unidentified and underdiagnosed, leading to mortality. A future ongoing goal should be to improve these conditions.

Volume: 3 Issue: 1 March 2023

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