Chapter 24: Trauma, Surgery, & Burns

Question 1

Define SIRS.

Answer 1

Systemic Inflammatory Response Syndrome (SIRS)

• Entails the presence of 2 out of 4 abnormal systems
  
  • Heart Rate
  • Respiratory Rate
  • Temperature
  • WBC count
• When 2 of these are met, the local injury of trauma or burn is producing a systemic reaction.

Question 2

Name some counter-regulatory hormones.

Answer 2

• Epinephrine
• Norepi
• Glucagon
• Cortisol

Named as such because they oppose the effects of insuling and other anabolic hormones. The responsiveness of tissues, especially skeletal muscle, to insulin is severly blunted.

Question 3

Name the 3 effective treatment strategies of SIRS.

Answer 3

1. Delivery of oxygen to vital tissues
2. Source control (control of bleeding, necrotic, and infected tissues)
3. Provision of nutrition support.

Question 4

Define mucosal acidosis.

Answer 4

A measure of reduced intraoperative splanchnic perfusion, is associated with:

• Exaggerated local and systemic immune responses
• Increased intestinal permeability
• Increase in septic complications
• A trend toward increased multiorgan dysfunction syndrome

Question 5

Define postprandial hyperemia.

Answer 5

The presence of luminal nutrients increases GI blood flow.

Question 6

(TRUE/FALSE)

Clinical and laboratory evidence suggests that EN is contraindicated with the use of vasopressive agents.

Answer 6

FALSE.

IT IS NOT contraindicated. Use of EN in such patients should be conservative, with the EN advanced only when the patient demonstrates tolerance. Following adequate resuscitation, EN may protect the GI tract, especially the mucosa, from relatively low levels of ischemia.

Question 7

(TRUE/FALSE)

Malnutrition related to stress or trauma differs from starvation-related malnutrition in that the former stems from increased resting energy expenditure and tremendous mobiliation of protein deposits.

Answer 7

TRUE.

It is driven by systemic inflammation. This systemic inflammation can drive catabolism to the severity of affecting cardiac mass and function. Which can continue for weeks to months after the patient is discharged from the ICU.

Noted as “acute-disease” or “injury-related malnutrition” to acknowledge this phenomenon.

Question 8

**ASPEN/SCCM guidelines recommend assessment using XXXXX or XXXXX to identify patients who would benefit from nutrition therapy.

Answer 8

• NRS-2002 (Nutrition Risk Screening)
  
  • Attempts to account for both preexisting malnutrition (ie: weight loss, decreased food intake) AND severity of illness (ie: type of injury, APACHE II score)
• NUTRIC (Nutrition Risk in Critically Ill)
  
  • Focus on severity of illness.

Question 9

What are the 3 main categories for surgical ICU patients?

Answer 9

1. Postoperative major elective surgery
2. Major injury (ie: burns and trauma)
3. Serious sepsis

Question 10

(TRUE/FALSE)

Body weight measured in the ICU is not a valid indicator of body cell mass.

Answer 10

TRUE.

Ideally, weight changes should be monitored weekly. Acute weight changes are most likely due to fluid shifts, as 1 L of fluid equals 1 kg body weight.

Question 11

(TRUE/FALSE)

Fluid shifts and increased permeability change the proportion of fluid to protein, effectively altering the measured concentration of serum proteins. Therefore, in patients with acute illness, inflammation, or injury (such as in the early postoperative period and in trauma and burn patients), transport proteins cannot reliably be regarded as a marker of nutrition status, but can only be interpreted as a marker of severity of illness and inflammation.

Answer 11

TRUE.

Albumin, prealbumin, transferrin, and retinol-binding protein, are negative acute phase response proteins.

Question 12

**How should energy needs be calculated in trauma patients?

Answer 12

**ASPEN/SCCM guidelines recommend using IC to measure resting energy expenditure in the critically ill, surgical, injured and burn patients, when it is available.

Question 13

Describe the “PEPuP protocol.”

Answer 13

• Driven by the bedside nurse
• Uses daily volume based goals, liberalizes the GRV threshold, and initiates protein supplementation with motility agents on Day 1 of a patient’s ICU stay.
• Increased protein delivery by 14% and energy by 12% in trial.

Question 14

Once a PEG tube is placed, how long do you have to wait until TF is initiated?

Answer 14

May be used for feeding within 2 hours; instead of the routine 24-hour delay.

Question 15

**What is the current recommendation for stressed patients (including those with burns), for protein?

Answer 15

• **20 to 25% of total nutrient intake by provided by protein
• Equates to ~ 1.5 to 2.0 g/kg/d, with the higher range to promote N equilibrium
• 2.0 g/kg/d IBW has been suggested for obese patients (BMI equal or greater than 30)
• In patients with large surface area burns, 3 to 4 g/kg/d may be required.

Question 16

(TRUE/FALSE)

It has been suggested that ICU patients receiving continuous renal replacement therapy (CRRT) should receive 2.0 to 2.5 g/kg/d to overcoe protein losses in the dialysate.

Answer 16

TRUE.

Question 17

What is the minimum amount of dextrose necessary to maintain CNS function?

Answer 17

120 g/day

Question 18

What are isomotic fluids (such as NS and lR) used for?

Answer 18

• Isomotic fluids or balanced electrolyte solutions are typically used for fluid and electrolyte replacement
• When these are used as maintenance, 5% dextrose will be added as an energy source (for protein sparing, prevention of ketosis and maintanence of stable glucose levels).

Question 19

What is the Parkland formula?

Answer 19

• Most commonly used method to determine adult fluid resuscitation requirements
• Used for patients with greater than 15% TBSA second- and third-degree burns.
  
  • (4 mL LR for X body weight (kg)) X (TBSA)
• One half of this total amount is administered in the first 8 hours after the burn
• The remaining amount is given over the next 16 hours, followed by maintenance fluids.
• Inhalation injury results in additional fluid needs and is often estimated as another 10% of TBSA.

Question 20

(FILL IN THE BLANK)

Monitoring urine output is an essential part of providing fluid to thermal injury patients, as adequate hydration should result in a minimum of XXXX.

Answer 20

• 0.3 to 0.5 mL/kg/hour

Question 21

What are the vitamin/mineral recommendations for burn patients with less than 20% TBSA and burn patients undergoing delayed reconstructive patients?

Answer 21

A daily MVI

Question 22

What are the vitamin and mineral recommendations for burn patients with greater than 20% TBSA?

Answer 22

• Daily MVI
• 20,000 IU Vitamin A
• 220 mg zinc
• 500 mg ascorbic acid BID

Selenium, copper and vitamin D may be considered if levels are low.

Question 23

**In previously well-nourished patients, when should PN be initiated, according to ASPEN/SCCM guidelines?

Answer 23

**Only after efforts to provide nutrition via the enteral route have failed to advance EN to meet 60% of target goal energy for 7 to 10 days.

EXCEPTIONS:

• Preexisting malnutrition
• Cannot receive EN
• Are expected to undergo major upper GI surgery

Question 24

**For patients that are in the ‘PN exception group,’ when should PN be initiated, according to ASPEN/SCCM guidelines?

Answer 24

**Patients include:

• Preexisting malnutrition
• Cannot receive EN
• Are expected to undergo elective major upper GI surgery

ASPEN/SCCM recommend that 5 to 7 days of preoperative PN be provided with continued PN postoperatively.

If EN was contraindicated and the malnourished GI surgery patient did not receive preoperative PN, ASPEN/SCCM recommend (based on limited data), that initiation of PN be delayed postoperatively for 5 to 7 days if EN continues to be contraindicated. PN provided for fewer than 5 days has not shown benefit.

Question 25

(TRUE/FALSE)

Some authors advocate small bowel feeding in critically ill patients because it is associated with decreased gastroesophageal reflux, reduced aspiration, and increase in nutrient delivery, and a shorter time to achieve desired nutrient delivery.

Answer 25

TRUE.

Question 26

In what situations as a clinician, should you recommend a small bore feeding tube?

Answer 26

Patients who are high risk for aspiration and gut dysmotility.

• Undergone major intra-abdominal surgery
• Prior episode of aspiration or emesis
• Persistent high GRVs (greater than 500 mL)
• Unable protect the airway
• Require prolonged supine or prone positioning.

Question 27

At what point, is it appropriate to switch to nighttime cycling EN?

Answer 27

May be considered when patients are meeting more than 60% of their energy goal by the oral route prior to discontinuing EN. To maximize intake, oral dietary restrictions are discouraged.

Question 28

What are the objectives of the ERAS protocol?

Answer 28

The objectives are to avoid starvation, decrease the physiological stress of surgery (which induces IR), and limit postoperative IV fluids, while optimizing pain control, GI function, and mobilization.

Question 29

What is the ERAS protocol?

Answer 29

• Avoid preoperative fasting:
  
  • Solid meals are provided up until 6 hours before surgery.
  • 800 mL (~ 100 g and 400 kcal) of a CHO-rich, CL is given at midnight and 400 mL of the same formula is given again 2 hours before the surgical intervention
• Patients receive a smaller volume of IV fluids

Question 30

**What are the ASPEN/SCCM guidelines for PN.

Answer 30

**PN should be reserved and initiated only after the first 7 days of hospitalization in patients WITHOUT malnutrition.

Question 31

(TRUE/FALSE)**

ASPEN/SCCM guidelines recommend that use of continuously administered enteral immunonutrition formulations with supplemental omega-3 FAs and arginine in postoperative and trauma ICU patients.

Answer 31

TRUE.**

Question 32

(TRUE/FALSE)**

ASPEN/SCCM guidelines recommend adding glutamine to EN for any critically ill.

Answer 32

FALSE**

NOT recommended adding until additional evidence is available.