Educational Paper Basics in clinical nutrition: Nutritional support in burn patients Meete Berger Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland article info Article history: Received 4 June 2009 Accepted 4 June 2009 Keywords: Pathophysiology Metabolic Nutrition Proteins Lipids Carbohydrates Learning objectives – To know the principles of fluid resuscitation in burn patients. – To be familiar with requirements for macronutrients and micronutrients in burn patients. – To know the methods of administering nutrition in burn patients. The incidence of burn injuries has decreased in Western coun- tries, but they remain a major problem throughout the world. Qualitatively, the metabolic responses of burn patients are similar to those of other trauma patients, although more severe, with a particularly intense acute phase. Burns also share similar addi- tional morbidity from shock, acute respiratory distress syndrome, sepsis, and multiple organ failure, which occur in any severely injured patient. Burned patients are frequently managed in sepa- rate facilities, and have some specific medical characteristics: – They suffer cutaneous exudative losses of fluids containing large quantities of protein, minerals and micronutrients, which cause acute deficiency syndromes. – Venous access is more difficult due to the destruction of the skin at the puncture sites (higher risk of catheter related infection). – The surface to repair is extensive and explains the requirement for prolonged nutritional support, which is rare in other trauma. – Burn patients stay for much longer periods in intensive care units (ICU) compared with other trauma, and require more prolonged nutritional support. 1. Pathophysiology 1.1. Fluid loss In the early phase of burns >20% of body surface, there is a transient massive increase in capillary permeability, with an obligatory plasma loss from the intravascular space into the extravascular compartment, which causes the generalised oedema in major burns. The loss is proportional to the extent of injury. In addition there are water evaporative losses, and plasma weeps from the burned area (exudation). The permeability changes last for about 24 h, being maximal during the first 12 h and are mainly responsible for the extensive fluid requirements. 1.2. Metabolic response The metabolic response to trauma is essentially biphasic, fol- lowed by a late recovery phase. 1. Immediately after injury, there is a period of haemodynamic instability with reduced tissue perfusion, and release of high levels of catecholamines. This initial phase has classically been called the «ebb phase». It is characterized by a lowered total oxygen consumption (VO 2 ), and low metabolic rate. Depending on the severity of injury and on the success of the haemody- namic resuscitation, it may be extremely short-lived and last a few hours, or persist for a few days depending on the severity of injury and the quality of resuscitation. 2. The ebb phase is progressively replaced by the «flow phase», characterized by high VO 2 , elevated resting energy expenditure E-mail address: espenjournals@espen.org (Editorial Office). Contents lists available at ScienceDirect e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism journal homepage: http://www.elsevier.com/locate/clnu 1751-4991/$ - see front matter Ó 2009 Published by Elsevier Ltd on behalf of European Society for Clinical Nutrition and Metabolism. doi:10.1016/j.eclnm.2009.06.005 e-SPEN, the European e-Journal of Clinical Nutrition and Metabolism 4 (2009) e308–e312