combust 2011

COMBUSTIONFajar Ari Nugroho

LUKA BAKAR

Merupakan luka yang disebabkan oleh panas,listrik, maupun bahan kimia Panas =

- benda panas: padat, cair, udara (uap)- api- sengatan matahari atau sinar panas

Listrik = aliran listrik tegangan tinggi Kimia = asam kuat, basa kuat

DIAGNOSIS LUKA BAKAR

Berdasar :1. Luas luka bakar2. Derajat (kedalaman) luka bakar3. Lokalisasi4. Penyebab

Penetapan Luas Luka Bakar

1. Rumus – 9 (Rule of Nine)2. Telapak tangan = 1%

Rumus – 9 (Rule of Nine)

Telapak tangan = 1%

Derajat Luka Bakar

Derajat IMengenai epidermis, lapisan basal masih baik, eritema, oedematus, nyeri

Derajat IIEpidermis dan dermis, bagian dasar kulit masih baik (IIa) superfisial (dangkal) : bulla, oedema, erithema, nyeri (IIb) deep (dalam) : hampir mengenai seluruh lapisan kulit

Derajat Luka Bakar

Derajat IIIseluruh lapisan kulit, tidak nyeri, jaringan putih, abu-abu, kecoklatan (nekrosis)

Fase Luka Bakar

Ebb-phase responsehypovolemic shock: 1. tissue perfusion2. metabolic rate3. oxygen consumption4. blood pressure5. body temperature

Fase Luka Bakar

Flow-phaseacute responses : 1. glucocorticoid2. glucagon3. catecholamin4. Release of cytokines, lipid mediators5. Production of acute-phase proteins6. excretion of nitrogen7. metabolic rate8. oxygen consumption9. Impaired use of fuels

Fase Luka Bakar

Flow-phase adaptive response

1. Hormonal response gradually disminishes2. hyper metabolic rate3. Associated with recovery4. Potential with restoration of body protein5. Wound healing depends in part on njutrient

intake

MNT principal

1. Because of difficulty in conducting a nutritional assessment in a critically ill patients (combust) the ability to predict, will resume adequate oral food intake

2. Must focus on laboratory data not to define nutritional status, but for design the nutritional prescription

MNT principal

3. Should review indices of organ system function, blood glucose, laboratory abnormalities, specially electrolytes & acid-base balance may impact enteral & parenteral formulation/diet order

4. Urine Urea Nitrogen (UUN) excretion in grams/day has been evaluate the degree of hyper metabolism : 5=no stress, 5-10=mild hyper metabolism (level 1 stress), 10-15=moderate hyper metabolism (level 2), >15=severe hyper metabolism (level 3)

Factor to consider

1. Pre injury nutritional status2. Type of trauma3. Extent of injury4. Surgical finding5. Gastrointestinal function6. Enteral access option

Fluid & electrolyte repletion

The first 24-48 hour treatment fluid & electrolyte replacement; the calculate volume for first 24-h given in first 8-h (the period of greatest intravascular loss); the volume of fluid needed age & weight, extent of the burn

Early adequate fluid preventing ischemia, maintaining circulatory volume

Encourage fluid intake = juice (stump) To determined fluid & electrolyte needs:1. Lund & border chart2. Baxter/parkland

calculation

Lund & browder2.0-3.1 mL/kg body weight/24-h/%TBSA = fluid volume

Baxter/parkland4 cc x BB x % TBSA = RL volume

Ket: TBSA the percentage body surface area (luas permukaan luka bakar); RL ringer laktat

NB: <15%+grade 2 oral, infus >15%; ½ hasil perhit 8 jam pertama, sisa ½ nya 16 jam berikutnya

Energy

Adult 1. Harris benedict

kebut energi (p) = 66+(13,7 x BB)+(5 x TB)–(6,8 x U) x AF x FSkebut energi (w) = 665 + (9,6 x BB) + (1,8 x TB)–(4,7 x U) x AF x FS

Note: meningkatkan resiko morbiditas dan mortalitas, terutama pada fase akut LB berat (overfeeding)

Energy

2. The curreri formula kebut energi = 24 Kcal x BBI + 40 Kcal x % TBSA burned (max 50% TBSA)

Note: bila TBSA >50%-60% minimal increases in energy expenditure occur; ketika formula ini digunakan hrs dipastikan penambahan kalori max 100% (2xREE); biasanya menghasilkan perhitungan > actual energy expenditure

Energy

3. Rule of thumbKebut energi = 25 – 30 Kal/KgBB

Note: merupakan metode perhitungan yang praktis

dan dapat menghindari overfeeding

Energy

Pediatric 1. Galveston formula

Kebut energi = 1800 Kcal/m2 + 2200 Kcal/m22. Polk formula

Kebut energi = (60 Kcal x kg body weight) x (35 Kcal x % burn)

Note: polk children less then 3 yrs

Considerable energy needs

Weight gain (severely underweight patient) not feasible until after the acute illness

Weight maintenance should be the goal overweight patient

For obese patient more than calculation when using ideal body weight, less than calculation when using actual body weight; indirect calorimetry is the most accurate methods of determining the energy needs

Energy sources

Carbohydrate are excellent for protein-sparing (60%, stump) recommended as the chief of energy source excess : lipogenesis causes oxygen consumption, CO2 production, hyperglicemia, osmotic diuresis, respiratory difficulty

Although lipids are a concentrate source of energy excess: deleterious immunologic response, susceptibility to infection

Diet high -3 increase immune response & tube feeding tolerance by: inhibit prostaglandin E2 & leucotrienes (immunosuppressive); a reasonable approach 15%-20% (krause), 20% fat (2-4% essential amino acid, slight in omega 3) (stump)

MCT & structured lipids under investigation

Protein

Losses trough urine & wound, increased use in gluconeogenesis & wound healing

20-25% recommended for adult (krause)or 1.5-3 g/kg BW (stump), 2.5- 3.0 g/kg BW for pediatric (pediatric: depend on renal function & fluid balance)

BCAAs seem to have no beneficial effect, the conditional essential amino acids: arginine may improve cell mediated immunity & wound healing, anabolic hormone production, (up to 2% of kcal) (stump); glutamine ability of neutrophils (krause);

Assessment of Energy & Protein Adequacy

The best evaluated by: 1) wound healing, 2) graft take, 3) basic nutritional assessment parameter

Weight change trends can be identified after fluid gained during resuscitation period in 2 weeks

Nitrogen balance is frequently used to evaluated the efficacy of nutrient regimen, but it can’t considered accurate without accounting for wound losses, the first 4 weeks may be the most reflective measure in nutritional monitoring

Assessment of Energy & Protein Adequacy

Formulas for predicting nitrogen losses:1. <10% open wound = 0.02 g nitrogen/kg/day2. 11-30% open wound = 0.05 g nitrogen/kg/day3. >31 open wound = 0.12 g nitrogen/kg/day Note: albumin levels remain depressed until major

burn are healed; prealbumin, RBP, transferin helping to assess protein status of patient

Vitamin & mineral

Vitamin needs increased, but exact requirement have not been establish

Recommended:1. Vitamin C = 500 mg twice daily (krause); 5-10 x RDA

(stump)2. Vitamin A = 5000 IU/1000 calories of enteral nutrition

(krause); 2 x RDA (stump)3. Sodium/potassium are corrected by adjusting fluid therapy

restriction sodium free water : correct hyponatremia; resuscitation & protein synthesis : hypokalemia (slightly : inadequate rehydration )

Vitamin & mineral

4. Depression of calcium levels may be seen in patient more than 30% TBSA (hypocalcemia : hypoalbuminemia) = supplement may necessary

5. Hypophospathemia large volume of resuscitation & large antacid = supplement via parenterally (prevent gastric irritation)

6. Magnesium levels loss from wound = supplement via parenterally (prevent gastric irritation)

Vitamin & mineral

7. Depressed zinc levels unclear : total body zinc nutriture or an artifact of hypoalbuminemia = supplementation 220 mg zinc sulfate is appropriate (krause); 2 x RDA zinc sulfate (stump)

8. Anemia usually unrelated to iron deficiency (no history) = packed red blood cell

9. Vitamin B-com 2-3 x RDA (stump)10. Vitamin B12 & K diberikan mingguan (stump)

Others

11. Use high calorie, high protein diet with 5-6 small meals & snack

12. Avoid excesses of linoleic acid depress immunocompetence

13. Be careful iron & zinc excess in patient with sepsis14. Do not alter nutritional support because watery

diarrhea is likely occur for reason other than carbohydrate intolerance

Beware Clinical indicator Clinical/history1. Height2. Preburn weight3. Weight change4. Daily weight

(beware of heavy exudates, edema)

5. BMI

6. Diet history7. Measured energy

expenditure8. % body burned9. Burn (calsification)10. Edema11. BP12. temperature

Beware Clinical indicator Clinical/history13. Urine aceton, sugars14. Ability to chew15. Ability to swallow16. Hypovolemic shock,

tachycardia, low BP, decrease urinary output

Lab1. Albumin

2. Transthyretin ()3. CRP, BUN, Creat4. Gluc, Na+, Chloride,

K+, Ca++, Mg++5. Partial pressure of CO2

(PCO2), O2 (PO2)13. Transferin, cholesterol,

TG, WBC14. Serum catecholamine

()15. N balance

DNI Analgesic = GI function & appetite Antacid = change digestion process Antibiotic = leaching of sodium, potassium,

magnesium, calcium & B-com Insulin = use for stress induce hyperglicemia Interferon gamma or alpha-2b = dry mouth,

stomatitis, nausea & vomiting, diarrhea, abdominal pain

Supportive therapy = no interaction

Refference Stump, S.E., (2008),Nutrition and

Diagnosis-Related Care, sixth edition, Philedelpia : lippincott

Mahan, K., (2000), Krause’s Food nutrition & Diet Therapy, USA: Saunders company

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