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Year : 2015  |  Volume : 4  |  Issue : 2  |  Page : 70-76

Nutritional concerns in critically ill burn patients

Department of Anaesthesiology and Intensive Care, Gian Sagar Medical College and Hospital, Banur, Punjab, India

Date of Web Publication4-Aug-2015

Correspondence Address:
Sukhminder Jit Singh Bajwa
House No. 27-A, Ratan Nagar, Tripuri, Patiala, Punjab
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Source of Support: Nil., Conflict of Interest: None declared.

DOI: 10.4103/2278-1870.162174

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Nutritional issues in critical care are very important for the better prognosis of patients. These concerns are further heightened if critically ill patients are admitted with co-morbidities and deranged physiology. A similar scenario is encountered when patients with burns are admitted in Intensive Care Units (ICU) for one indication or the other. Their short and long-term prognosis mainly depends on prevention of infection and maintenance of optimal nutritional status. The aim of the current manuscript is to review some of the challenging aspects in critically ill-patients admitted in ICU with history of burns.

Keywords: Burns, critically ill-patients, enteral nutrition, intensive care

How to cite this article:
Bajwa SJ, Kaur G. Nutritional concerns in critically ill burn patients. J Med Nutr Nutraceut 2015;4:70-6

How to cite this URL:
Bajwa SJ, Kaur G. Nutritional concerns in critically ill burn patients. J Med Nutr Nutraceut [serial online] 2015 [cited 2024 Mar 2];4:70-6. Available from: http://www.jmnn.org/text.asp?2015/4/2/70/162174

  Introduction Top

Nutritional supplementation is an integral part of therapeutic management in critically ill patients. The challenges increased manifold if these patients are admitted with co-morbidities, trauma or any other complication. Management of critically ill burn patients is extremely challenging to the attending intensivist. The gross pathophysiological changes, altered fluid dynamics, vulnerability to infections, metabolic derangements, electrolyte disturbances and severity of burns influence largely the nutritional parameters and therapeutic interventions. Ever since the evolution of critical care services, attempts have been continuously made by the researchers to improve and optimize the nutritional status in critically ill-patients. The evolving guidelines and protocols of nutritional therapy in critically sick patients can be extrapolated to burn patients also in Intensive Care Unit (ICU), which has largely been supported by the emergence of evidence-based medicine. The current manuscript is aimed at discussing important issues pertaining to the nutritional supplementation of patients admitted with varying degree of burns to the ICU.

  Search strategies Top

The present manuscript is an attempt to highlight the understanding of the nutritional aspects in patient with burns. The measures adopted included extensive scrutiny of literary evidence from internet resources, journals and textbooks of surgery, nutrition, anesthesiology and intensive care. The strategies included exploration of full-text articles and abstracts from various search engines such as PubMed, Medscape, Scopus, Science Direct, Medline, Yahoo, Google Scholar and many others, which included keywords such as enteral nutrition, burns, intensive care, critically ill-patients.

  Current Recommendations and Guidelines! Top

At present, various guidelines set up by European Society for Clinical Nutrition and Metabolism are typically followed in the ICU. ALLIANCE is one of the international organizations, which is working at international as well as at Indian level to set up the nutritional goals. Scope of enteral nutrition has improved with the endoscopic placement of jejunostomy and gastrostomy feeding tubes. Development of various new bio-markers of illness can also be of great help in guiding the nutritional goals. Research in the field of pharmaco-genomics has also linked the role of nutrition in gene expression.[1]

Besides aggressive fluid management in burn patients, nutritional supplementation is gaining enhanced clinical significance. Such patients present with numerous clinical challenges which have to be identified at the earliest so as to achieve clinical stability. Management of these patients needs a multidisciplinary approach. The inhalational injury can lead to airway edema, fluid-electrolyte balance, thermoregulatory aspects and risk of infectious complications. Inadequate nutrition in critically ill patients impairs ventilatory drive and weakness of respiratory muscles, thus increasing hospital stay. Nutrition supplies important cell substrates and vital nutrients. Severe form of burn injury is associated with the hypermetabolic state. Various nutrients and many other agents have been found to have their impact on the reversal of the this hypermetabolic state.[2] This hyperdynamic circulatory state is seen if burns are more than 40% of total body surface area (TBSA) and leads to massive protein and lipid breakdown resulting in muscle wasting. Hyperglycemia occurs due to peripheral insulin resistance. Increase in the levels of various hormones such as catecholamines, glucocorticoids, glucagon and dopamine is responsible for this catabolic state.[3] This altered metabolic state starts within days of burn injury and may persist for several years after burns.[4] Morbidity and mortality increases to a significant extent as severe burn injury can affect each and every organ of the body.[5] This increased mortality can be reduced significantly with the use of high protein diet along with early excision and grafting of burn wounds.[6] It has been concluded from previous studies that early and aggressive enteral feeding can improve the outcome by normalizing the intestinal blood flow and by modulating the hypermetabolic response. Enteral nutrition is preferred over parenteral nutrition as the former one reduces bacterial translocation, also maintains the motility of intestine and thus increases the absorption of nutrients.[7] Parenteral nutrition is usually reserved for those patients who cannot tolerate enteral feed or have ileus. Postburn ileus mainly affects stomach and colon and spares small intestine. Thus in burn patients, early enteral feed within 6 h can be started via duodenal or jejunal routes.[8],[9]

Nutrition plan of the burn patients should include site, type and percentage of burns, age of the patient and any other preexisting medical disorders. These factors are important as patients having burns more than 10% of TBSA along with burns of the face, genitalia, etc., need special care. Children with burns more than 10% of TBSA and patients with inhalational or electrical burns need to be managed very carefully. Preexisting medical disorders can enhance the mortality.[10]

  Nutritional Requirements Top

Energy requirement in the acute phase can be calculated from resting energy expenditures (REE). However, increase is variable over time and mainly takes TBSA into consideration. The concept of hyperalimentation was followed earlier, but REE increase is seen during the 1st week, and it decreases thereafter. It has also been seen that if the feed is given according to 25–30 kcal/kg/day, chances of under feeding are more.[11],[12] Overfeeding also increases morbidity. The aim of nutritional support should be to maintain the lean body mass as hypermetabolic state results in catabolism in severe burns. Indirect calorimetry is now considered as the gold standard to calculate energy requirements in burn patients. Measurements are made in the fed state, and the results of the analysis are rounded to the upper 100 value, without exceeding + 10% of the measured value. Carbohydrates form the major source of energy as these provide glucose for metabolic pathways, spare amino acids and also serve as fuel for wound healing but should not be more than 60% of total energy intake and should not be more than 5 mg/kg/min that is, 7 g/kg/day.[13] Fat should not be more than 30–35% of nonprotein calories because the hypermetabolic response in these patients suppresses lipolysis and limit their breakdown to be used as source of energy.[14] Use of low-fat diet is advisable in severe burns. Use of omega-3 fatty acids has been seen to be associated with improved outcome as compared to the use of omega-6 fatty acids as metabolism of the former is associated without invoking any inflammatory response.[15],[16] Protein catabolism is also common in burn patients, which can decrease lean body mass and patients get more prone to infections. Burn patients need 1.5–2 g/kg/day of the proteins in feed.[17][18][19]

Formulas to calculate resting metabolic expenditure (RME) are as follows:[20]

Mathematical formula to estimate RME:

Males = (66.5) + (13.7 × W) + (5 × H) − (6.8 × A).

Females = (655.1) + (9.6 × W) + (1.8 × H) − (4.7 × A).

W: Weight (kg)

H: Height (cm)

A: Age (years)

Above mentioned formula is for healthy, febrile individuals. In patients with burns more than 30%, RME increases by 100%.

Carbohydrates should provide 30–70% of total calories needed. Fats should provide 20–50% and proteins approximately 15–20% of total energy requirement.[21]

Formula to calculate REE is:

REE (Kcal) = −4343+ (10.5 × TBSA burned) + (0.23 × Kcal) + (0.84 × Harris Benedict) + (114 × T°C) − (4.5 × days postburn).

Kcals = calories intake in past 24 h.

Harris Benedict = basal requirement in calories using the Harris Benedict equation with no stress factors or activity factors.

T = body temperature in degrees celsius.

Days postburn = the number of days after the burn injury is sustained using the day itself as day zero.

  Role of Glutamine Top

Glutamine acts as a main energy source for enterocytes and lymphocytes. It is one of the important transport amino acid. It performs various functions asit acts as a source of energy for hepatocytes, maintains integrity, permeability and immune function of small intestine and improves wound healing.[11],[12] The dose of glutamine supplementation is around 0.3 g/kg/day.[13]

  Role of Visceral Proteins in Critically Ill Patients Top

Visceral proteins include albumin, transferrin, transthyretin and retinol-binding proteins. These proteins are mostly synthesized in the liver. Inflammation and impaired liver functions result in low blood levels of visceral proteins. Hypoalbuminemia occurs in critically ill patients due to “capillary leak syndrome” with albumin escaping through more permeable capillaries into the interstitium. Distribution of albumin gets affected with an infusion of various fluids used for volume resuscitation of sick patients. Hence, albumin cannot be used for assessment and monitoring of the nutritional status.[21] In one of the studies in the literature, relationship between visceral proteins and clinical outcome has been assessed in 107 burned patients with biweekly measurements from day 12 to day 43 postburn. It has been observed that levels of albumin and transthyretin increase more consistently and rapidly in patients with burns <50% of BSA, whereas further decline was reported for those who died between day 20 and day 43.[22] It has also been observed that transthyretin levels <50 mg/dl or failure to increase of 40 mg/L/week are associated with poor prognosis.[23],[24]

It has also been seen in previous several studies that immunonutrition rich in nucleotides and (omega)-3 fish oil decreases the mortality rate along with decrease in recurrence rate of bacteraemia in sick patients in intensive care.[25]

  Other Important Nutritional Aspects in Burn Patients Top

Burn patients need sedation and analgesia very frequently, so these are at increased risk of constipation. Thus, their diet should be rich in fibers. Early enteral feed via gastric route is preferred in these patients as it is associated with attenuation of the stress response, stress-induced ulcers and increased production of immunoglobulins. Few factors can prevent early start of enteral feeding as in the initial phase of resuscitation, larger amounts of crystalloids used, can lead to edema of the intestine and paralytic ileus. Enhanced capillary leak in the early phase of burns increases the fluid requirement.[26]

Micronutrient supplementation reduces the mortality and morbidity in critically ill patients as their deficiency results in lowered host defenses and impaired production of antioxidants. Also, the intravenous route is best for their supplementation. Duration, dose and timing of giving these micronutrients are the important considerations for improving their utility.[27] Thus the addition of copper, zinc, selenium, Vitamin B1, C, D, E to feed is of great helpful. Copper, zinc and selenium are lost in larger amounts in burn patients in the exudate. Their supplementation decreases fat breakdown, improved wound healing, and thus shorter hospital stay. Thiamine replacement improves lactate and pyruvate metabolism. Vitamin C and E supplementation enhance wound healing. Their dose should be 1.5–3 times higher than recommended daily intake. Loss of Vitamin D is also needed to prevent bone loss. Increased oxidative stress in burn patients is associated with enhanced depletion of micronutrients. Several other measures like warm ambient temperature (28–30° centigrade), nonselective beta blockers (propranolol) and oxandrolone are also important measures, which prevent hypermetabolism and hyper catabolism in burn patients.[13] Beta blockers, by reducing heart rate by 20% attenuate stress hormone release. Propranolol can be started at the end of the 1st week of burns.[28],[29] Oxandrolone in a dose of 10 mg/12 h decrease mortality and thus hospital stay in burn patients.[30],[31] There is no role of arginine supplementation according to the recent review.[32] Ornithine alpha-ketoglutarate is precursor and thus an alternative to glutamine, it’s use during acute phase after burns improves nitrogen balance.[33]

  Glucose Control in Burn Patients Top

Target glucose levels between 5 and 8 mmol/L has been seen to be associated with several clinical benefits such as better graft uptake, lesser infectious complications and ultimately decreased mortality. 100–150 mg/dl is a standard target, which is otherwise maintained in other critical patients in ICU.[34],[35] Exenatide, a new incretin, which inhibits glucagon secretion can decrease external insulin requirement in pediatric burn patients.[36]

Adequate pain control and physiotherapy are also essential in early rehabilitation of these patients.[13]

  Enteral Versus Parenteral Nutrition Top

The enteral nutrition maintains the integrity of intestine by maintaining tight junctions between intraepithelial cells, enhance intestinal blood flow and induce the release of cholecystokinin, gastric, bombesin and bile salts. It also maintains villous height and support IgA producing immunocytes. Within hours of major insult, intestinal permeability changes due to loss of functional integrity thus increasing the risk and severity of infectious complications.[37],[38]

Indications of enteral nutrition:[39],[40]

Major reason for preference of enteral nutrition over parenteral nutrition is decrease in morbidity with the use of enteral nutrition due to reduction in the incidence of central venous line-related infections, pneumonia and abdominal abscess in trauma patients.[41] In several studies, benefits in the form of a decrease in hospital stay, cost of nutrition and regain of the cognitive function in head injury patients has been seen with enteral nutrition.[42],[43] Five of the various six meta-analysis done in the literature has shown no difference in the mortality between enteral and parenteral form of nutritional therapies.[42],[44][45][46][47] In a study done by Simpson and Doig, despite the higher incidence of infectious complications with use of parenteral nutrition, significantly lower mortality has been seen as compared to enteral nutrition.[48]

Enteral feeding should be started early within first 24–48 h after admission, once fluid resuscitation is complete and patient is hemodynamically stable. Feed should be advanced towards desired target within next 48–72 h. In a study by Marik and Zaloga, a significant reduction in infectious morbidity and hospital stay has been seen with early enteral nutrition when compared to delayed start.[49] If patients are on high dose of inotropes or vasopressors and need excessive volumes of fluids for resuscitation, due to chances of sub-clinical ischemia or reperfusion injury to the gut, enteral nutrition should be withheld.[50]

As bowel sounds are indicative of contractile movements and it is not necessary that these indicate integrity of bowel mucosa, absorptive capacity and barrier function. Main reasons for intestinal dysfunction in critically ill patients are mucosal barrier dysfunction, mucosal atrophy, reduced gut-associated lymphoid tissue and dysmotilty. [50,51] Hence in critical patients, neither the presence or absence of bowel sounds and passage of stools is mandatory for initiating enteral feed.[51] And also if sick patients show intolerance to gastric feeding, are at high risk of aspiration and have high residual volume, can be started on small bowel feed. There is also an evidence that if early enteral nutrition has not been started within 7 days, parenteral nutrition can be started.[50] As permeability if intestine increases during 1st week of severe burns, there is need to provide > 50–65% of the desired target. During first 7–10 days, parenteral nutrition supplementation has not been found out to be helpful. Braunschweig et al. and Sandström et al. have also concluded from their study that after first 7–10 days, requirement for proteins and energy are increased in order to prevent complications due to poor nutritional status. Thus, if we are unable to meet the energy requirement of the sick patient by 100% of the target level needed, parenteral nutrition can be supplemented.[43],[51] Studies in the literature have also shown that those patients who receive larger volume of enteral nutrition, encounter less complications and thus less associated morbidity than patients receiving lower feed amount.[43],[53] There are various indications of enteral nutrition as listed in [Table 1].
Table 1: Indications of enteral nutrition

Click here to view

Obese patients are at higher risk of infections, deep vein thrombosis, insulin resistance, etc., So protein supplementation in a dose of 2–2.5 g/kg of ideal body weight/day and 60–70% of caloric requirement enhance neutral nitrogen balance and promote wound healing.[52] To prevent problems associated with ileus and inadequate nutrient delivery, time for fasting before or after any procedure should be kept minimum possible.[50]

Various tests are needed in patients receiving total parenteral nutrition in the form of total blood count, B12 and folate levels, serum magnesium, phosphate, calcium, glucose, liver function tests, serum albumin, prealbumin, C-reactive protein zinc and copper levels. Investigations to be done in patients on total parenteral nutrition have been mentioned in [Table 2], as written below.
Table 2: list of investigations to be done in patients recieving total parenteral nutrition

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Frequency of tests can be reduced once the patient is stable. Complete attention should be given to peripheral lines for signs of thrombophlebitis and centrally sited lines for signs of infection or inflammatory changes.[54]

  Dietary Modifications in Special Situations Top

Endocrine disorders

It has also been studied in the literature that normal functioning of many endocrine organs like thyroid, pancreas etc., is also linked to the nutritional status. Thus nutritional imbalance can hamper their normal functioning. Various endocrine disorders such as obesity, thyroid disorders and diabetes have been linked with dietary modifications. Increased prevalence of endocrine disorders have been seen with over nutrition. Dietary patterns actually programme the different mechanisms associated with these disorders. As in case of diabetes mellitus, presence of transcription factor TCF7L2 has been linked, which can be regulated by fat and glucose rich diet. All the dietary components affect endocrine system of body.[55]

Chronic kidney disease

Dietary modifications both improve symptomatology as well as progression of kidney diseases. Many factors like type and severity of renal disease, nutritional status, dry weight, dietary intake, co-morbid diseases, physical activity, biochemical markers and also the adjusted body weight help in calculation of energy requirement of these patients.[56]

  Challenging Aspects Top

Present challenges and possible measures which can be taken in developing countries may include but are not limited to:

  • Limited availability of indirect calorimetry in ICU
  • Scarcity of availability of bio-markers of illness, which can improve in molecular basis of the different pathological conditions
  • Extensive search is needed in field of tight glycemic control, pharmaco-nutrition and immune-nutrition
  • Need to carry out randomized control trials and studies to make guidelines
  • Lesser funds are available for health services.

Our own guidelines and recommendations should be made according to the Indian scenario after extensive research and studies. These guidelines need to be followed strictly in ICU as per the institutional resources. Training programmes should be conducted for training of the staff.


Limitations of current review article may include but are not limited to lesser number of randomized controlled trials, paucity of universal guidelines, different beliefs and cultural practices in our country, different food fads, socio-religious factors etc., which can have either direct or indirect effect on the nutritional aspects in burn patients.

  References Top

Bajwa SS. Nutritional facts in critically ill patients: The past, present and the future. J Med Nutr Nutraceuticals 2014;3:6-10.  Back to cited text no. 1
Atiyeh BS, Gunn SW, Dibo SA. Metabolic implications of severe burn injuries and their management: A systematic review of the literature. World J Surg 2008;32:1857-69.  Back to cited text no. 2
Gauglitz GG. Hypermetabolic response to severe burn injury: Recognition and treatment. Crit Care Clin 2001;17:107.  Back to cited text no. 3
Pereira CT, Herndon DN. The pharmacologic modulation of the hypermetabolic response to burns. Adv Surg 2005;39:245-61.  Back to cited text no. 4
Herndon DN, Tompkins RG. Support of the metabolic response to burn injury. Lancet 2004;363:1895-902.  Back to cited text no. 5
Williams FN, Branski LK, Jeschke MG, Herndon DN. What, how, and how much should patients with burns be fed? Surg Clin North Am 2011;91:609-29.  Back to cited text no. 6
Mochizuki H, Trocki O, Domimioni L, Brackett KA, Joffe SN, Alexander JW. Mechanism of prevention of post burn hyper metabolism and catabolism by early enteral feeding. Ann Surg 1984;200:297-310.  Back to cited text no. 7
Tinckler LF. Surgery and Intestinal motility. Br J Surg 1965;52:140-50.  Back to cited text no. 8
Moss G. Maintenance of gastrointestinal function after bowel surgery and immediate enteral full nutrition. II. Clinical experience, with objective demonstration of intestinal absorption and motility. JPEN J Parenter Enteral Nutr 1981;5:215-20.  Back to cited text no. 9
Clinical Practice Guidelines Nutrition Burn Patient Management NSW Statewide Burn Injury Service. Version 3; 2011. Available from: http://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0009/162639/SBIS_Nutrition_CPG_new_format.pdf. [Last cited on 2015 Mar 21].  Back to cited text no. 10
Cunningham JJ. Factors contributing to increased energy expenditure in thermal injury: A review of studies employing indirect calorimetry. JPEN J Parenter Enteral Nutr 1990;14:649-56.  Back to cited text no. 11
Rimdeika R, Gudaviciene D, Adamonis K, Barauskas G, Pavalkis D, Endzinas Z. The effectiveness of caloric value of enteral nutrition in patients with major burns. Burns 2006;32:83-6.  Back to cited text no. 12
Rousseau AF, Losser MR, Ichai C, Berger MM. ESPEN endorsed recommendations: Nutritional therapy in major burns. Clin Nutr 2013;32:497-502.  Back to cited text no. 13
Demling RH, Seigne P. Metabolic management of patients with severe burns. World J Surg 2000;24:673-80.  Back to cited text no. 14
Alexander JW, Saito H, Trocki O, Ogle CK. The importance of lipid type in the diet after burn injury. Ann Surg 1986;204:1-8.  Back to cited text no. 15
Huschak G, Zur Nieden K, Hoell T, Riemann D, Mast H, Stuttmann R. Olive oil based nutrition in multiple trauma patients: A pilot study. Intensive Care Med 2005;31:1202-8.  Back to cited text no. 16
Saffle JR, Graves C. Nutritional support of the burned patient. In: Herndon DN, editor. Total Burn Care. 3rd ed. London: Saunders Elsevier; 2007. p. 398-419.  Back to cited text no. 17
Norbury WB, Herndon DN. Modulation of the hypermetabolic response after burn injury. In: Herndon DN, editor. Total Burn Care. 3rd ed. New York: Saunders and Elsevier; 2007. p. 420-33.  Back to cited text no. 18
Matthews DE, Marano MA, Campbell RG. Splanchnic bed utilization of leucine and phenylalanine in humans. Am J Physiol 1993;264:E109-18.  Back to cited text no. 19
Bajwa SJ, Gupta S. Controversies, principles and essentials of enteral and parenteral nutrition in critically ill-patients. J Med Nutr Nutraceuticals 2013;2:77-83.  Back to cited text no. 20
Bajwa SS, Kulshrestha A. Critical nutritional aspects in intensive care patients. J Med Nutr Nutraceuticals 2012;1:9-16.  Back to cited text no. 21
Manelli JC, Badetti C, Botti G, Golstein MM, Bernini V, Bernard D. A reference standard for plasma proteins is required for nutritional assessment of adult burn patients. Burns 1998;24:337-45.  Back to cited text no. 22
Bernstain L. Measurement of visceral protein status in assessing protein and energy malnutrition: Standard of care. Prealbumin in Nutritional Care a Consensus Group. Nutrition 1995;11:169-71.  Back to cited text no. 23
Weimann A, Bastian L, Bischoff WE, Grotz M, Hansel M, Lotz J. Influence of arginine, omega-3fatty acids and nucleotide-supplemented enteral support on systemic inflammatory response syndrome and multiple organ failure in patients after severe trauma. Nutrition 1998;14:165-72..  Back to cited text no. 24
Deitch EA. Intestinal permeability is increased in burn patients shortly after injury. Surgery 1990;107:411-6.  Back to cited text no. 25
Herndon DN, Hart DW, Wolf SE, Chinkes DL, Wolfe RR. Reversal of catabolism by beta-blockade after severe burns. N Engl J Med 2001;345:1223-9.  Back to cited text no. 26
Bajwa SJ. The underestimated nutritional aspects of micronutrients supplementation in intensive care. J Med Nutr Nutraceuticals 2013;2:114-6.  Back to cited text no. 27
Arbabi S, Ahrns KS, Wahl WL, Hemmila MR, Wang SC, Brandt MM, et al. Beta-blocker use is associated with improved outcomes in adult burn patients. J Trauma 2004;56:265-9.  Back to cited text no. 28
Pham TN, Klein MB, Gibran NS, Arnoldo BD, Gamelli RL, Silver GM, et al. Impact of oxandrolone treatment on acute outcomes after severe burn injury. J Burn Care Res 2008;29:902-6.  Back to cited text no. 29
Wolf SE, Edelman LS, Kemalyan N, Donison L, Cross J, Underwood M, et al. Effects of oxandrolone on outcome measures in the severely burned: A multicenter prospective randomized double-blind trial. J Burn Care Res 2006;27:131-9.  Back to cited text no. 30
Yan H, Peng X, Huang Y, Zhao M, Li F, Wang P. Effects of early enteral arginine supplementation on resuscitation of severe burn patients. Burns 2007;33:179-84.  Back to cited text no. 31
Coudray-Lucas C, LeBever H, Cynober L, DeBandt JP, Carsin H. Ornithine a-ketoglutarate improves wound healing in severe burn patients: A prospective randomized double-blind trial versus isonitrogenous controls. Crit Care Med 2000;28:1772-6.  Back to cited text no. 32
Gore DC, Chinkes D, Heggers J, Herndon DN, Wolf SE, Desai M. Association of hyperglycemia with increased mortality after severe burn injury. J Trauma 2001;51:540-4.  Back to cited text no. 33
Pidcoke HF, Wanek SM, Rohleder LS, Holcomb JB, Wolf SE, Wade CE. Glucose variability is associated with high mortality after severe burn. J Trauma 2009;67:990-5.  Back to cited text no. 34
Mecott GA, Herndon DN, Kulp GA, Brooks NC, Al-Mousawi AM, Kraft R, et al. The use of exenatide in severely burned pediatric patients. Crit Care 2010;14:R153.  Back to cited text no. 35
Kudsk KA. Current aspects of mucosal immunology and its influence by nutrition. Am J Surg 2002;183:390-8.  Back to cited text no. 36
Jabbar A, Chang WK, Dryden GW, McClave SA. Gut immunology and the differential response to feeding and starvation. Nutr Clin Pract 2003;18:461-82.  Back to cited text no. 37
Kang W, Kudsk KA. Is there evidence that the gut contributes to mucosal immunity in humans? JPEN J Parenter Enteral Nutr 2007;31:246-58.  Back to cited text no. 38
Ammori BJ, Leeder PC, King RF, Barclay GR, Martin IG, Larvin M, et al. Early increase in intestinal permeability in patients with severe acute pancreatitis: Correlation with endotoxemia, organ failure, and mortality. J Gastrointest Surg 1999;3:252-62.  Back to cited text no. 39
Kudsk KA, Croce MA, Fabian TC, Minard G, Tolley EA, Poret HA, et al. Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg 1992;215:503-11.  Back to cited text no. 40
Heyland DK, Dhaliwal R, Drover JW, Gramlich L, Dodek P, Canadian Critical Care Clinical Practice Guidelines Committee. Canadian clinical practice guidelines for nutrition support in mechanically ventilated, critically ill adult patients. JPEN J Parenter Enteral Nutr 2003;27:355-73.  Back to cited text no. 41
Taylor SJ, Fettes SB, Jewkes C, Nelson RJ. Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med 1999;27:2525-31.  Back to cited text no. 42
Braunschweig CL, Levy P, Sheean PM, Wang X. Enteral compared with parenteral nutrition: A meta-analysis. Am J Clin Nutr 2001;74:534-42.  Back to cited text no. 43
Gramlich L, Kichian K, Pinilla J, Rodych NJ, Dhaliwal R, Heyland DK. Does enteral nutrition compared to parenteral nutrition result in better outcomes in critically ill adult patients? A systematic review of the literature. Nutrition 2004;20:843-8.  Back to cited text no. 44
Moore FA, Feliciano DV, Andrassy RJ, McArdle AH, Booth FV, Morgenstein-Wagner TB, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg 1992;216:172-83.  Back to cited text no. 45
Peter JV, Moran JL, Phillips-Hughes J. A metaanalysis of treatment outcomes of early enteral versus early parenteral nutrition in hospitalized patients. Crit Care Med 2005;33:213-20.  Back to cited text no. 46
Simpson F, Doig GS. Parenteral vs. enteral nutrition in the critically ill patient: A meta-analysis of trials using the intention to treat principle. Intensive Care Med 2005;31:12-23.  Back to cited text no. 47
Marik PE, Zaloga GP. Early enteral nutrition in acutely ill patients: A systematic review. Crit Care Med 2001;29:2264-70.  Back to cited text no. 48
McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, et al. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2009;33:277-316.  Back to cited text no. 49
Mutlu GM, Mutlu EA, Factor P. Prevention and treatment of gastrointestinal complications in patients on mechanical ventilation. Am J Respir Med 2003;2:395-411.  Back to cited text no. 50
Sandström R, Drott C, Hyltander A, Arfvidsson B, Scherstén T, Wickström I, et al. The effect of postoperative intravenous feeding (TPN) on outcome following major surgery evaluated in a randomized study. Ann Surg 1993;217:185-95.  Back to cited text no. 51
Martin CM, Doig GS, Heyland DK, Morrison T, Sibbald WJ, Southwestern Ontario Critical Care Research Network. Multicentre, cluster-randomized clinical trial of algorithms for critical-care enteral and parenteral therapy (ACCEPT). CMAJ 2004;170:197-204.  Back to cited text no. 52
Choban PS, Dickerson RN. Morbid obesity and nutrition support: Is bigger different? Nutr Clin Pract 2005;20:480-7.  Back to cited text no. 53
National Collaborating Centre for Acute Care(UK). Nutrition a Support for Adults: Oral Nutrition Support, Enteral Tube Feeding and Parenteral Nutrition. London: Nation Collaborating Centre for Acute care(UK);2006 Feb. (NICE Clinical Guidelines, No.32). Available from: http://www.ncbi.nlm.nih.gov/books/NBK49269/.   Back to cited text no. 54
Bajwa SJ, Sethi E, Kaur R. Nutritional risk factors in endocrine diseases. J Med Nutr Nutraceuticals 2013;2:86-90.  Back to cited text no. 55
Bajwa SS, Kwatra IS. Nutritional needs and dietary modifications in patients on dialysis and chronic kidney disease. J Med Nutr Nutraceuticals 2013;2:46-51.  Back to cited text no. 56


  [Table 1], [Table 2]

This article has been cited by
1 Fungemia Related to Parenteral Nutrition
Cecilia Quesada,Jorge Aceituno,Ronaldo Suárez,Celso Mazariegos
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[Pubmed] | [DOI]


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Role of Glutamine
Role of Visceral...
Other Important ...
Glucose Control ...
Enteral Versus P...
Dietary Modifica...
Challenging Aspects
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