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

Abstract

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.