World Journal of Surgery

, Volume 32, Issue 8, pp 1857–1869 | Cite as

Metabolic Implications of Severe Burn Injuries and Their Management: A Systematic Review of the Literature

  • Bishara S. Atiyeh
  • S. William A. Gunn
  • Saad A. Dibo
Article

Abstract

Background

Severe burn patients are some of the most challenging critically ill patients, with an extreme state of physiologic stress and an overwhelming systemic metabolic response. A major component of severe burn injury is a hypermetabolic state associated with protein losses and a significant reduction of lean body mass. The second prominent component is hyperglycemia. Reversal of the hypermetabolic response by manipulating the patient’s physiologic and biochemical environment through the administration of specific nutrients, growth factors, or other agents, often in pharmacologic doses, is emerging as an essential component of the state of the art in severe burn management. The present review aims at summarizing the new treatment modalities established to reduce the catabolic burden of severe burn injuries, for which there is some evidence-based support.

Methods

A systematic review of the literature was conducted. Search tools included Elsevier ScienceDirect, EMBASE.com, Medline (OVID), MedlinePlus, and PubMed. Topics searched were Nutrition and Burns, Metabolic Response and Burns, Hypermetabolism and Burns, Hyperglycemia and Burns, and several more specific topics when indicated. With a focus on the most recently published articles, abstracts were reviewed and, when found relevant, were included as references. Full text articles, whenever available, were retrieved.

Results

Many issues remain unanswered. Unfortunately, the present state of our knowledge does not allow the formulation of clear-cut guidelines. Only general trends can be outlined, and these will certainly have some practical applications but above all will dictate future research in the field.

References

  1. 1.
    Ipaktchi K, Arbabi S (2006) Advances in burn critical care. Crit Care Med 34:S239–S244PubMedGoogle Scholar
  2. 2.
    Rodriguez DJ (1996) Nutrition in patients with severe burns: state of the art. J Burn Care Rehabil 17:62–70PubMedGoogle Scholar
  3. 3.
    Noordenbos J, Hansbrough JF, Gutmacher H et al (2000) Enteral nutritional support and wound excision and closure do not prevent postburn hypermetabolism as measured by continuous metabolic monitoring. J Trauma 49:667–672PubMedGoogle Scholar
  4. 4.
    Dolecek R (1985) The endocrine response after burns: its possible correlations with the immunology of burns. J Burn Care Rehabil 6:281–294PubMedGoogle Scholar
  5. 5.
    Nguyen T, Gilpin D, Meyer N et al (1996) Current treatment of severely burned patients. Ann Surg 1:14–25Google Scholar
  6. 6.
    Pidcoke H, Wade C, Wolf S (2007) Insulin and the burned patient. Crit Care Med 3:S524–S530Google Scholar
  7. 7.
    Gore D, Chinkes D, Hart D et al (2002) Hyperglycemia exacerbates muscle protein catabolism in burn injured patients. Crit Care Med 30:2438–2442PubMedGoogle Scholar
  8. 8.
    Jahoor F, Desai M, Herndon DN et al (1988) Dynamics of the protein metabolic response to burn injury. Metabolism 37:330–337PubMedGoogle Scholar
  9. 9.
    Sheridan RL, Tompkins RG, Burke JK (1994) Management of the burn wound using prompt eschar excision and immediate biologic closure. J Intensive Care Med 9:6–17PubMedGoogle Scholar
  10. 10.
    Atiyeh B, Gunn S, Hayek S (2005) New technologies for burn wound closure and healing—review of the literature. Burns 31:944–956PubMedGoogle Scholar
  11. 11.
    Atiyeh B, Gunn S, Hayek S (2005) State of the art in burn treatment. World J Surg 29:131–148PubMedGoogle Scholar
  12. 12.
    Long C (1979) Energy expenditure for major burns. J Trauma 19:904–906PubMedGoogle Scholar
  13. 13.
    Hasselgren PO (1999) Burns and metabolism. J Am Coll Surg 188:98–103PubMedGoogle Scholar
  14. 14.
    Arturson MG (1978) Metabolic changes following thermal injury. World J Surg 2:203–214PubMedGoogle Scholar
  15. 15.
    Hill AG, Hill GL (1998) Metabolic response to severe injury. Br J Surg 85:884–890PubMedGoogle Scholar
  16. 16.
    Arnold L (2000) Burns and metabolism. J Am Coll Surg 190:104–114Google Scholar
  17. 17.
    Pereira C, Herndon H (2005) The pharmacologic modulation of the hypermetabolic response to burns. Adv Surg 39:245–261PubMedGoogle Scholar
  18. 18.
    Hart W, Wolf E, Mlcak R et al (2000) Persistence of muscle catabolism after severe burn. Surgery 128:312–319PubMedGoogle Scholar
  19. 19.
    Pereira T, Murphy D, Herndon N (2005) Altering metabolism. J Burn Care Rehab 26:194–199Google Scholar
  20. 20.
    Reiss W, Pearson E, Artz CP (1956) The metabolic response to burns. J Clin Invest 35:62–77PubMedGoogle Scholar
  21. 21.
    Wanek S, Wolf S (2007) Metabolic response to injury and role of anabolic hormones. Curr Opin Clin Nutr Met Care 10:272–277Google Scholar
  22. 22.
    Moore FD (1953) Bodily changes during surgical convalescence. Ann Surg 137:289–295PubMedGoogle Scholar
  23. 23.
    Purdue F (2007) American burn association presidential address 2006 on nutrition: yesterday, today, and tomorrow. J Burn Care Res 28:1–5PubMedCrossRefGoogle Scholar
  24. 24.
    Caldwell T (1991) Etiology and control of postburn hypermetabolism. J Burn Care Rehabil 12:385–401PubMedGoogle Scholar
  25. 25.
    Jacobs G, Jacobs O, Kudsk A et al (2004) The East practice management guidelines work group practice management guidelines for nutritional support of the trauma patient. J Trauma Injury Infect Crit Care 57:660–679Google Scholar
  26. 26.
    Wilmore W, Curreri W, Spitzer W et al (1971) Supranormal dietary intake in thermally injured hypermetabolic patients. Surg Gynecol Obstet 132:881–886PubMedGoogle Scholar
  27. 27.
    Wilmore W, Long N, Mason AD et al (1974) Catecholamines: mediator of the hypermetabolic response to thermal injury. Ann Surg 180:653–669PubMedGoogle Scholar
  28. 28.
    Dancey R, Hayes J, Gomez M et al (1999) ARDS in patients with thermal injury. Intensive Care Med 25:1231–1236PubMedGoogle Scholar
  29. 29.
    Davis A, Santaniello M, He K et al (2004) Burn injury and pulmonary sepsis: development of a clinically relevant model. J Trauma 56:272–278PubMedGoogle Scholar
  30. 30.
    Sasaki J, Fujishima S, Iwamura H et al (2003) Prior burn insult induces lethal acute lung injury in endotoxemic mice: effects of cytokine inhibition. Am J Physiol Lung Cell Mol Physiol 284:270–278Google Scholar
  31. 31.
    Piccolo T, Wang Y, Verbrugge S et al (1999) Role of chemotactic factors in neutrophil activation after thermal injury in rats. Inflammation 23:371–385PubMedGoogle Scholar
  32. 32.
    Hansbrough F, Wikstrom T, Braide M et al (1996) Neutrophil activation and tissue neutrophil sequestration in a rat model of thermal injury. J Surg Res 61:17–22PubMedGoogle Scholar
  33. 33.
    Bessey Q, Watters M, Aoki T et al (1984) Combined hormonal infusion simulates the metabolic response to injury. Ann Surg 200:264–269PubMedGoogle Scholar
  34. 34.
    Linares HA (1982) A report of 115 consecutive autopsies in burned children, 1966–1980. Burns 8:263–270Google Scholar
  35. 35.
    Joshi W (1970) Effects of burns on the heart. JAMA 211:2130–2134PubMedGoogle Scholar
  36. 36.
    Yu YM, Tompkins RG, Ryan CM et al (1999) Tissue fuel and weight loss after injury. JPEN J Parenter Enteral Nutr 23:160–168PubMedGoogle Scholar
  37. 37.
    Holm C, Hörbrand F, Mayr M et al (2004) Acute hyperglycaemia following thermal injury: friend or foe? Resuscitation 60:71–77PubMedGoogle Scholar
  38. 38.
    Peck D, Kessler M, Cairns A et al (2004) Early enteral nutrition does not decrease hypermetabolism associated with burn injury. J Trauma 57:1143–1149PubMedGoogle Scholar
  39. 39.
    Sheridan L, Tompkins G (2004) What’s new in burns and metabolism. J Am Coll Surg 198:243–263PubMedGoogle Scholar
  40. 40.
    Murphy D, Lee O, Herndon N (2003) Current pharmacotherapy for the treatment of severe burns. Expert Opin Pharmacother 4:369–384PubMedGoogle Scholar
  41. 41.
    Vaughan G, Mason A, Shirani K et al (1985) Hormonal changes following burns: an overview with consideration of the pineal gland. J Burn Care Rehab 6:275–280Google Scholar
  42. 42.
    Shamoon H, Hendler R, Sherwin RS (1981) Synergistic interactions among anti-insulin hormones in the pathogenesis of stress hyperglycemia in humans. J Clin Endocrinol Metab 52:1235–1241PubMedGoogle Scholar
  43. 43.
    Becker RA, Vaughan GM, Ziegler MG et al (1982) Hypermetabolic low triiodothyronine syndrome of burn injury. Crit Care Med 10: 870–875PubMedGoogle Scholar
  44. 44.
    Bobek S, Sechman A, Wieczorek E et al (1996) Responses of heat stressed chickens to exogenous reverse triiodothyronine (rT3). Zentralblatt fur Veterinarmedizin - Reihe A. 43:521–530PubMedGoogle Scholar
  45. 45.
    Chen XL, Xia ZF, Ben DF et al (2007) Insulin resistance following thermal injury: an animal study. Burns 33:480–483Google Scholar
  46. 46.
    Carter ERA, Tompkins G, Babich JW et al (1996) Thermal injury in rats alters glucose utilization by skin, wound, and small intestine, but not by skeletal muscle. Metabolism 45:1161–1167PubMedGoogle Scholar
  47. 47.
    Jahoor F, Desai MH, Herndon DN et al (1998) Dynamics of protein anabolic response to burn injury. Metabolism 37:330–337Google Scholar
  48. 48.
    Wolfe R, Herndon N, Jahoor F et al (2000) Persistence of muscle catabolism after severe burn. Surgery 232:455–465Google Scholar
  49. 49.
    Shangraw R, Jahoor F, Miyoshi H et al (1989) Differentiation between septic and postburn insulin resistance. Metabolism 38:983–989PubMedGoogle Scholar
  50. 50.
    Jahoor F, Shangraw RE, Miyoshi H et al (1989) Role of insulin and glucose oxidation in mediating the protein catabolism of burns and sepsis. Am J Physiol 1 257:E323–E331Google Scholar
  51. 51.
    Carlson I (2003) Insulin resistance in sepsis. Br J Surg 90:259–260PubMedGoogle Scholar
  52. 52.
    Kahn B, Flier S (2000) Obesity and insulin resistance. J Clin Invest 106:473–481PubMedGoogle Scholar
  53. 53.
    Matthaei M, Stumvoll M, Haring H (2000) Pathophysiology and pharmacological treatment of insulin resistance. Endocr Rev 21:585–618PubMedGoogle Scholar
  54. 54.
    Zhang Q, Carter E, Ma BY et al (2005) Molecular mechanism(s) of burn-induced insulin resistance in murine skeletal muscle: role of IRS phosphorylation. Life Sci 77:3068–3077PubMedGoogle Scholar
  55. 55.
    Schwacha MG, Chaudry IH (2002) The cellular basis of post-burn immunosuppression: macrophages and mediators. Int J Mol Med 10:239–243PubMedGoogle Scholar
  56. 56.
    Ikezu T, Okamoto T, Yonezawa K et al (1997) Analysis of thermal injury-induced insulin resistance in rodents. Implication of postreceptor mechanisms. J Biol Chem 40:25289–25295Google Scholar
  57. 57.
    Zick (2001) Insulin resistance: a phosphorylation-based uncoupling of insulin signalling. Trends Cell Biol 11:437–441Google Scholar
  58. 58.
    Rui L, Aguirre V, Kim JK et al (2001) Insulin/IGF-1 and TNF-alpha stimulate phosphorylation of IRS-1 at inhibitory Ser307 via distinct pathways. J Clin Invest 107:181–189PubMedGoogle Scholar
  59. 59.
    Van den Berghe G, Wouters P, Weekers F et al (2001) Intensive insulin therapy in critically ill patients. N Engl J Med 345:1359–1367PubMedGoogle Scholar
  60. 60.
    Pidcoke H, Salinas J, Wanek S et al (2007) Patterns of exogenous insulin requirement reflect insulin sensitivity changes in trauma. Am J Surg 1945:798–803Google Scholar
  61. 61.
    Gore D, Chinkes D, Heggers J et al (2001) Association of hyperglycemia with increased mortality after severe burn injury. J Trauma 51:540–544PubMedGoogle Scholar
  62. 62.
    Saffle J, Larson C, Sullivan J (1990) A randomized trial of indirect calorimetry-based feedings in thermal injury. J Trauma 30:776–783PubMedGoogle Scholar
  63. 63.
    Mowlavi A, Andrews K, Milner S et al (2000) The effects of hyperglycemia on skin graft survival in the burn patient. Ann Plast Surg 45:629–632PubMedGoogle Scholar
  64. 64.
    Rassias AJ, Marrin CA, Arruda J et al (1999) Insulin infusion improves neutrophil function in diabetic cardiac surgery patients. Anesth Analg 88:1011–1016PubMedGoogle Scholar
  65. 65.
    Jenkins E, Gottschlich M, Warden D (1994) Enteral feeding during operative procedures in thermal injuries. J Burn Care Rehabil 15:199–205PubMedGoogle Scholar
  66. 66.
    Gore C, Herndon N, Wolfe R (2005) Comparison of peripheral metabolic effects of insulin and metformin following severe burn injury. J Trauma 59:316–322PubMedGoogle Scholar
  67. 67.
    Gore DC, Wolf SE, Sanford A et al (2005) Influence of metformin on glucose intolerance and muscle catabolism following severe burn injury. Ann Surg 241:334–342PubMedGoogle Scholar
  68. 68.
    Berger M, Chioléro L (2007) Hypocaloric feeding: pros and cons. Curr Opin Crit Care 13:180–186Google Scholar
  69. 69.
    McCowen C, Friel C, Sternberg J et al (2000) Hypocaloric total parenteral nutrition: effectiveness in prevention of hyperglycemia and infectious complications—a randomized clinical trial. Crit Care Med 28:3606–3611PubMedGoogle Scholar
  70. 70.
    Campbell T (1999) Limitations of nutrient intake. The effect of stressors: trauma, sepsis and multiple organ failure. Eur J Clin Nutr 53:143–147Google Scholar
  71. 71.
    Pham N, Warren J, Phan H et al (2005) Impact of tight glycemic control in severely burned children. J Trauma 59:1148–1154PubMedCrossRefGoogle Scholar
  72. 72.
    Pidcoke F, Wade E, Wolf E (2007) Insulin and the burned patient. Crit Care Med 35:S524–S530PubMedGoogle Scholar
  73. 73.
    Cochran A, Davis L, Morris S et al (2008) Safety and efficacy of an intensive insulin protocol in a burn-trauma ICU. J Burn Care Res 29:187–191PubMedGoogle Scholar
  74. 74.
    Kimball R, Jurasinski V, Lawrence C et al (1997) Insulin stimulates protein synthesis in skeletal muscle by enhancing the association of eIF-4E and eIF-4G. Am J Physiol 272:C754–C759PubMedGoogle Scholar
  75. 75.
    Gore C, Wolf E, Herndon N et al (2002) Relative influence of glucose and insulin on peripheral amino acid metabolism in severely burned patients. J Parenter Enteral Nutr 26:271–277Google Scholar
  76. 76.
    Geerlings E, Hoepelman I (1999) Immune dysfunction in patients with diabetes mellitus (DM). FEMS Immunol Med Microbiol 26:259–265PubMedGoogle Scholar
  77. 77.
    Jeschke MG, Klein D, Herndon DN (2004) Insulin treatment improves the systemic inflammatory reaction to severe trauma. Ann Surg 239:553–560PubMedGoogle Scholar
  78. 78.
    Wu X, Thomas SJ, Herndon DN et al (2004) Insulin decreases hepatic acute phase protein levels in severely burned children. Surgery 135:196–202PubMedGoogle Scholar
  79. 79.
    Thomas SJ, Morimoto K, Herndon DN et al (2002) The effect of prolonged euglycemic hyperinsulinemia on lean body mass after severe burn. Surgery 132:341–347PubMedGoogle Scholar
  80. 80.
    Dandona P, Aljada A, Morhanty P et al (2001) Insulin inhibits intranuclear nuclear factor kappa B and stimulates I kappa B in mononuclear cells in obese subjects: evidence for an anti-inflammatory effect? J Clin Endocrinol Metab 86:3257–3265PubMedGoogle Scholar
  81. 81.
    Przkora R, Herndon DN, Finnerty CC et al (2007) Insulin attenuates the cytokine response in a burn wound infection model. Shock 27:205–208PubMedGoogle Scholar
  82. 82.
    Gore C, Wolf E, Herndon N et al (2003) Metformin blunts stress-induced hyperglycemia after thermal injury. J Trauma 54:555–561PubMedGoogle Scholar
  83. 83.
    Wilmore W, Allick H (1978) Metabolic changes in burned patients. Surg Clin North Am 58:1173–1187PubMedGoogle Scholar
  84. 84.
    Herndon D, Tompkins R (2004) Support of the metabolic response to burn injury. Lancet 363:1895–1902PubMedGoogle Scholar
  85. 85.
    Mangano T, Layug L, Wallace A et al (1996) Effect of atenolol on mortality and cardiovascular morbidity after noncardiac surgery: multicenter study of perioperative ischemia research group. N Engl J Med 335:1713–1720PubMedGoogle Scholar
  86. 86.
    Wallace A, Layug B, Tateo I et al (1998) Prophylactic atenolol reduces postoperative myocardial ischemia. McSPI research group. Anesthesiology 88:7–17PubMedGoogle Scholar
  87. 87.
    Herndon N, Tompkins G (2004) Support of the metabolic response to burn injury. Lancet 363:1895–1902PubMedGoogle Scholar
  88. 88.
    McArdle H, Palmason C, Brown RA et al (1984) Early enteral feeding of patients with major burns: prevention of catabolism. Ann Plast Surg 13:396–401PubMedGoogle Scholar
  89. 89.
    Dominioni L, Trocki O, Mochizuki H et al (1984) Prevention of severe post burn hypermetabolism and catabolism by immediate intragastric feeding. J Burn Care Rehabil 5:106–112Google Scholar
  90. 90.
    Dominioni L, Trocki O, Fang CH et al (1985) Enteral feeding in burn hypermetabolism: nutritional and metabolic effects at different levels of calorie and protein intake. JPEN J Parenter Enteral Nutr 9:269–279PubMedGoogle Scholar
  91. 91.
    Prass K, Meisel C, Hoflich C et al (2003) Stroke-induced immunodeficiency promotes spontaneous bacterial infections and is mediated by sympathetic activation reversal by poststroke T helper cell type 1-like immunostimulation. J Exp Med 198:725–736PubMedGoogle Scholar
  92. 92.
    Cree M, Asle A, Herndon D et al (2007) Role of fat metabolism in burn trauma-induced skeletal muscle insulin resistance. Crit Care Med 35:S476–S483PubMedGoogle Scholar
  93. 93.
    Aarsland A, Chinkes D, Wolfe RR et al (1996) Beta-blockade lowers peripheral lipolysis in burn patients receiving growth hormone: rate of hepatic very low density lipoprotein triglyceride secretion remains unchanged. Ann Surg 223:777–787; discussion, 787–779PubMedGoogle Scholar
  94. 94.
    Morio B, Irtun O, Herndon DN et al (2002) Propranolol decreases splanchnic triacylglycerol storage in burn patients receiving a high-carbohydrate diet. Ann Surg 236:218–225PubMedGoogle Scholar
  95. 95.
    Arbabi S, Ahrns KS, Wahl WL et al (2004) Beta-blocker use is associated with improved outcomes in adult burn patients. J Trauma 56:265–69; discussion, 269–271PubMedGoogle Scholar
  96. 96.
    Mabuchi N, Tsutamoto T, Kinoshita M (2000) Therapeutic use of dopamine and beta-blockers modulates plasma interleukin-6 levels in patients with congestive heart failure. J Cardiovasc Pharmacol 36:S87–S91PubMedGoogle Scholar
  97. 97.
    Moore FA, Feliciano DV, Andrassy RJ et al (1992) Early enteral feeding, compared with parenteral, reduces post operative septic complications: the results of a meta-analysis. Ann Surg 216:172–183PubMedGoogle Scholar
  98. 98.
    Levy J, Turkish A (2002) Protective nutrients. Curr Opin Gastroenterol 18:717–722Google Scholar
  99. 99.
    Heyland D, Dhaliwal R (2005) Immunonutrition in the critically ill: from old approaches to new paradigms. Intensive Care Med 31:501–503PubMedGoogle Scholar
  100. 100.
    Kieft H, Roos AN, van Drunen JD et al (2005) Clinical outcome of immunonutrition in a heterogeneous intensive care population. Intensive Care Med 31:524–532PubMedGoogle Scholar
  101. 101.
    Neu J, Bernstein H (2002) Update on host defense and immunonutrients. Clin Perinatol 29:41–64PubMedGoogle Scholar
  102. 102.
    Wischmeyer PE, Lynch J, Liedel J et al (2001) Glutamine administration reduces gram-negative bacteremia in severely burned patients: a prospective, randomized, double-blind trial versus isonitrogenous control. Crit Care Med 29:2075–2080PubMedGoogle Scholar
  103. 103.
    Garrel D, Patenaude J, Nedelec B et al (2003) Decreased mortality and infectious morbidity in adult burn patients given enteral glutamine supplements: a prospective, controlled, randomized clinical trial. Crit Care Med 3:2444–2449Google Scholar
  104. 104.
    Zhou YP, Jiang ZM, Sun YH et al (2003) The effect of supplemental enteral glutamine on plasma levels, gut function, and outcome in severe burns: a randomized, double-blind, controlled clinical trial. JPEN J Parenteral Enteral Nutr 27:241–245Google Scholar
  105. 105.
    Hayashi N, Tashiro T, Yamamori H et al (1999) Effect of intravenous omega-6 and omega-3 fat emulsions on nitrogen retention and protein kinetics in burned rats. Nutrition 15:135–139PubMedGoogle Scholar
  106. 106.
    Zhou Y, Jiang Z, Sun Y (1999) Glutamine dipeptide enriched enteral nutrition improving gut permeability in severe burns. [Chinese] Chung-Hua i Hsueh Tsa Chih [Chinese Med J] 79:825–827Google Scholar
  107. 107.
    Spies M, Wolf SE, Barrow RE et al (2002) Modulation of types I and II acute phase reactants with insulin-like growth factor-1/binding protein-3 complex in severely burned children. Crit Care Med 30:83–88PubMedGoogle Scholar

Copyright information

© Société Internationale de Chirurgie 2008

Authors and Affiliations

  • Bishara S. Atiyeh
    • 1
  • S. William A. Gunn
    • 2
  • Saad A. Dibo
    • 3
  1. 1.Division Plastic and Reconstructive SurgeryAmerican University of Beirut Medical CenterBeirutLebanon
  2. 2.WHO Collaborating Center on Burns and Fire DisastersLa PanetiereSwitzerland
  3. 3.Department of SurgeryAmerican University of Beirut Medical CenterBeirutLebanon

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