Nutrición en el paciente quemado, ¿existe una dieta ideal? / Nutrition in the burn patient, is there an ideal diet? / Nutrição no paciente queimado, existe uma dieta ideal?

Resumen: La nutrición es uno de los pilares clave en el tratamiento de los pacientes con quemaduras severas, ya que a consecuencia de las quemaduras se desarrolla una de las respuestas fisiopatológicas caracterizadas por un estado de hipercatabolismo e hipermetabolismo con una pérdida secundaria de masa magra, tejido adiposo, vitaminas y oligoelementos condicionando alteraciones en el funcionamiento orgánico. Por lo tanto, es de extrema importancia dar el aporte nutricional de manera adecuada, sin caer en una infraalimentación o sobrealimentación, para lo que se requieren diversos métodos matemáticos para poder calcular el gasto calórico perdido, y de esta manera evitar complicaciones secundarias. En el presente trabajo se abarcan estos mecanismos fisiopatológicos, así como las técnicas y los requerimientos necesarios para alcanzar una nutrición adecuada en los pacientes con quemaduras severas.

Abstract: Nutrition is one of the key pillars in the treatment of patients with severe burns, since as a consequence of the burns, one of the pathophysiological responses is developed characterized by a state of hypercatabolism and hypermetabolism with a secondary loss of lean mass, adipose tissue, vitamins and trace elements conditioning alterations in organic functioning. Therefore, it is extremely important to give the nutritional contribution in an adequate way, without falling into an infra or supra feeding, for which various mathematical methods are required to be able to calculate the lost caloric expenditure, and in this way avoid secondary complications. This work covers these pathophysiological mechanisms, as well as the techniques and requirements necessary to achieve adequate nutrition in patients with severe burns.

Resumo: A nutrição é um dos pilares fundamentais no tratamento de pacientes com queimaduras graves, pois uma das respostas fisiopatológicas desenvolvidas em decorrência das queimaduras é caracterizada por um estado de hipercatabolismo e hipermetabolismo com perda secundária de massa magra, tecido adiposo, vitaminas e oligoelementos condicionando alterações no funcionamento orgânico. Portanto, é de extrema importância brindar o aporte nutricional de forma adequada, sem cair em uma sub ou superalimentação, para a qual são necessários vários métodos matemáticos para poder calcular o gasto calórico perdido e, assim, evitar complicações secundárias. Este artigo aborda esses mecanismos fisiopatológicos, bem como as técnicas e os requisitos necessários para alcançar uma nutrição adequada em pacientes com queimaduras graves.

Burn Institute of Southwest Hospital and I / 中华烧伤杂志

Dr. Wang has engaged in surgery and burn medicine for 61 years. He is one of the first generation of burn doctor in China, who treated burn patients more than ten thousands and went to dozens of cities and areas to rescue the wounded near hundred batches. He made contribution to the establishment of Chinese special scheme for treating burn patients. He established the institute lab of metabolism and nutrition in 1985, and treated burn patients and carried out research of burn metabolism and nutrition simultaneously. He developed new theory that other routes like internal organs especially intestine besides burn wound can induce hypermetabolism i. e." enterogenous hypermetabolism" . If gut works, early feeding (EF) and enteral nutrition (EN) are better than delayed feeding and parenteral nutrition, and EN or EF can promote gastrointestinal resuscitation, reduce intestine injury, modulate hypothalamus and pituitary function, and decrease hypermetabolism. At the end of the 1980s, by measuring the resting energy expenditure of 105 adult burn patients and normal adults, they worked out the first formula for calories supply in Chinese burn adults. He published 340 papers, while 50 papers were exchanged in international meeting, and published 53 monographs (as editor or associate editor in chief for 9 books). Metabolism and Nutrition in Burns is the 1st burn metabolism and nutrition book in China. We got 24 awards of nation, army, and provincial and ministerial level in science, technology, medicine, and education, and there were two awards of " National 2nd Science and Technology Award" (respectively the 1st and 2nd author). He was the chairman of Burn Institute of Southwest Hospital during 1988-1999, and the institute was appraised as " Model Unit of Grass-roots in General Logistics Department" and awarded the 1st and the 2nd collective merits during that time. He was the vice president of Chinese Burn Association and chief editor of Chinese Journal of Burns.

Advances in the research of relationship between brown or beige fat and hypermetabolism after severe burn / 中华烧伤杂志

Hypermetabolism is one of the remarkable characteristics of burn injury. Prolonged hypermetabolism causes insufficient energy supply, which leads to delayed wound healing, immune system dysfunction, increased infection rate, and multi-organ failure. In recent years, it is concerned that the activation of brown or beige adipose tissue may be related to hypermetabolism in severe burn patients. Brown or beige adipose tissue could be regulated by stress hormones and some cytokines which increase and persist in high level for several months after severe burn. This paper reviews the current knowledge of brown or beige adipocytes developmental lineages, molecular regulation mechanism, and regulation of brown or beige adipocytes activation after severe burn.

Hipermetabolismo temporal izquierdo en síndrome de Landau-Kleffner demostrado con PET F18-FDG: reporte de un caso con remisión metabólico-clínica postratamiento / Left temporal hypermetabolism detected in Landau-Kleffner syndrome with F18-FDG PET/CT: report of a case with metabolic and clinical remission after treatment

Brain F18-FDG Positron Emission Tomography (PET) has been used for studying focal epilepsy, with high sensitivity in detection of epileptogenic foci, even with normal magnetic resonance imaging (MRI). Some cases of Landau-Kleffner Syndrome (LKS) have shown PET abnormalities, mostly showing uni- or bilateral temporoparietal hypometabolism, although a heterogeneous group of alterations have been described. We report a case of LKS with a left hypermetabolic temporo-occipital area that responded to treatment, with clinical improvement and remission of PET hypermetabolic focus.

La positron emission tomography (PET) cerebral con F18-FDG ha sido utilizado para estudiar epilepsias focales con alta sensibilidad en la detección del área epileptógena, aun con resonancia magnética (RM) normal. La PET ha mostrado positividad en algunos casos de síndrome de Landau-Kleffner (SLK), la mayoría de las veces evidenciando hipometabolismo temporoparietal uni o bilateral, aunque un grupo heterogéneo de alteraciones asociadas ha sido descrito. Presentamos un caso de SLK con un área hipermetabólica temporooccipital izquierda, que respondió al tratamiento, con mejoría clínica y regresión del foco hipercaptante a la PET.

Hypermetabolism in sepsis / 中国小儿急救医学

The energy metabolism of septic patients is serious disorder.The major manifestation is protein degradation,the enhancement of glyconeogenesis and the adipose lipid mobilization.This may be link to abnormal ways of inflammatory media,the hormone secretion and ubiquitin-proteasome caused by sepsis.The discussion on high metabolic mechanism of sepsis,has great significance for guiding clinical practice,promoting targeted interventions and treatment measures and improving the prognosis of patients.This article summarized the progress on hyper metabolism in sepsis.

Aspectos básicos de la nutrición enteral en el paciente quemado / Basic aspects of the enteral nutrition in the burned patient

El tratamiento nutricional es un elemento importante en la terapia combinada de las lesiones por quemaduras severas, permitiendo un control del catabolismo en el paciente. En los pacientes quemados el hipermetabolismo estimula el aumento de las necesidades proteico calóricas, la influencia del inicio precoz de la nutrición apoya la estabilidad hemodinámica. El objetivo de esta revisión es describir los aspectos esenciales y actuales de la nutrición enteral en el paciente gran quemado como su concepto, vías de administración, importancia de su aplicación, fórmulas principales para el cálculo proteico energético, tratamiento con macronutrientes y micronutrientes para garantizar una nutrición adecuada y acorde a las necesidades. La nutrición enteral continua siendo la vía más importante y segura en el paciente gran quemado para la administración de macronutrientes y micronutrientes necesarios en los procesos metabólicos que garantizan la cicatrización y curación de los mismos(AU)

The nutritional treatment is an important element in the combined therapy of lesions from severe burns, thus allowing a control of catabolism in the patient, Hypermetabolism in burned patients encourages the increase of caloric protein requirements, the influence of early starting of nutrition supports the hemodynamic stability. The objective of this review was to describe the essential and present aspects of the enteral nutrition in the widely burned patient such as routes of administration, importance of application, main formulae for the energetic and protein calculations, treatment with macronutrients and micronutrients to guarantee adequate nutrition according to the requirements. Enteral nutrition continues being the most important and safest route of administration in the widely burned patient for giving him macronutrients and micronutrients that are necessary in the metabolic processes to assure cicatrization and healing(AU)

Aspectos nutricionales en la enfermedad de Graves: comunicación de un caso / Nutritional aspects in Graves' disease: case report

Introduction: An increased basal metabolism rate and hyperphagia associated with weight loss are among the main clinical manifestations of hyperthyroidism. However, few literature reports are available regarding the adequacy of calorie consumption based on the energy expenditure of the patient. Case Report: A 24-year-old male patient (weight 61.5 kg, height 1.78 m) with a diagnosis of hyperthyroidism due to Graves' disease and initial hormone values consistent with this disease (free T3=17,6 pg/ml; free T4>6,0 ng/dl; TSH<0,004 IU/ml). Indirect calorimetry was performed in order to estimate real energy expenditure and adequacy of the nutritional conducts adopted during hospitalization. The patient had a resting energy expenditure of2574 kcal. Conclusion: The present study suggests that the measurement of energy expenditure by indirect calorimetry is an important tool for the evaluation of the energy requirements and diet adequacy of a patient with thyrotoxicosis due to Graves' disease.

Introducción: El aumento del metabolismo basal, hiperfagia asociada con pérdida de peso son algunas de las principales manifestaciones clínicas que ocurren en el hipertiroidismo. Sin embargo, hay pocos estudios disponibles acerca de la necessidad y del gasto energético del paciente. Caso clínico: Varón de 24 años de edad con 61,5 kg de peso y estatura de 1,78 m, con el diagnóstico de hipertiroidismo por enfermedad de Graves (T3 libre = 17,6 pg/ml; T4 livre >6,0 ng/dl; TSH <0,004 IU/ml) y con los siguientes síntomas: pérdida de peso, aumento de apetito y hiperactividad. La calorimetría indirecta se realizó para estimar el consumo energético real para definir la conduta nutricional durante la hospitalización. El gasto energético basal fue de 2574 kcal. Conclusión: El presente estudio sugiere que la medición del gasto energético por calorimetría indirecta es una herramienta importante para la evaluación de las necesidades de energía y la adecuación de la dieta de un paciente con tirotoxicosis por enfermedad de Graves. Se necesitan más estudios para determinar el impacto de esta conducta en la evaluación de la respuesta al tratamiento del hipertiroidismo.

Regulation effect of insulin on the hypermetabolism of the skeletal muscles of septic patients through ubiquitin-proteasome pathway / 肠外与肠内营养

Hypermetabolism syndrome,especially in skeletal muscles,is exceedingly common in septic patients.Many studies suggest that the activity of ubiquitin-proteasome pathway is a vital procedure for hypermetabolism of skeletal muscles of septic patients and its activation can be influenced by a variety of factors,such as proinflammatory cytokine and glucocorticoid,etc.Evidences indicate that insulin has played an important role in opsonizing the activation of ubiquitin-proteasome pathway.This paper reviews the regulation effect of insulin to the hypermetabolism of the skeletal muscles of septic patients through ubiquitin-proteasome pathway.

Paroxysmal Horizontal Diplopia Related to Brainstem Lesion

Paroxysmal diplopia and dysarthria-ataxia have been reported in multiple sclerosis, stroke and Behcet's disease. We present a case of 25-year-old man with multiple brain lesions, who developed paroxysmal horizontal dysconjugate eyeball deviation, dysarthria and ataxia. Subtraction ictal SPECT co-registered to MR images demonstrated hyperperfusion in the brainstem and cerebellum during the paroxysms.

Effects of the APACHE III Score, Hypermetabolic Score on the Nutrition Status and Clinical Outcome of the Patients Administered with Total Parenteral Nutrition and Enteral Nutrition / 대한지역사회영양학회지

The aim of this study is to evaluate the clinical outcome. Between January 1, 2002 to September 30, 2002, we prospectively and retrospectively recruited 111 hospitalized patients who received Enteral Nutrition (ENgroup n = 52) and Total Parenteral Nutrition (TPNgroup n = 59) for more than seven days. The factors of clinical outcomes are costs, incidences of in-fection, lengths of hospital stay, and changes in weight. The characteristics of patients were investigated, which included nutritional status, disease severity (APACHE III score) and hypermetabolic severity (hypermetabolic score). Hypermeta-bolic scores were determined by high fever (>38 degrees C), rapid breathing (>30 breaths/min), rapid pulse rate (>100 beats/min), leukocytosis (WBC > 12000 mm3), leukocytopenia (WBC < 3000 mm3), status of infection, inflammatory bowel disease, surgery and trauma. There was a positive correlation between hypermetabolic score and length of hospital stay (ICU), medical cost, weight loss, antibiotics adjusted by age while APACHE III score did not show correlation to clinical outcome. Medical cost was higher by 18.2% in the TPN group than the EN group. In conclusion, there was a strong negative correlation between the clinical outcome (cost, incidence of infection, hospital stay) and hypermetabolic score. Higher metabolic stress caused more malnutrition and complications. For nutritional management of patients with malnutrition, multiple factors, including nutritional assessment, and evaluation of hypermetabolic severity are needed to provide nutritional support for critically ill patients.

The Outcome of Nutrition Support of Surgery Patients with Hypermetabolic Severity by Total Parenteral Nutrition and Enteral Nutrition and Biochemical Data / 대한지역사회영양학회지

This study evaluated the nutrition intake and changes in laboratory data of surgery patients with hypermetabolic severity on nutrition support. From January 2002 to September 2002, 66 hospitalized surgery patients who had received enteral nutrition (EN, n=19) and total parenteral nutrition (TPN, n=47) for more than 7 days were prospectively and retrospectively recruited. The laboratory data was examined pre-operatively, and on the post-operative 1, 3, 7 day and at the time of discharge. The characteristics of the patients were examined for the hypermetabolic severity, The hypermetabolic scores were determined by high fever (> 38 degrees C), rapid breathing (> 30 breaths/min), rapid pulse rate (> 100 beats/min), leukocytosis (WBC>12,000/microliter), leukocytopenia (WBC41). According to the results of the study, 38.3% (n=23), 45.4% (n=30) and 19.6% (n=13) were in the mild, moderate, and severe groups, respectively. There was a decrease in the serum albumin level and weight loss according to the hypermetabolic severity. However, the white blood cells (WBC), fasting blood sugar (FBS), c-reactive protein (CRP), total bilirubin, GOT, and GPT increased. The nutritional intake was TPN (32.5 kcal/kg, protein 1.2 g/kg, fat 0.25 g/kg), EN (28.1 kcal/kg, protein 1.0 g/kg, fat 1.01 g/kg). The serum albumin, hemoglobin and cholesterol were higher in the EN group than in the TPN group. But the FBS, total bilirubin, GOT and GPT were higher in the TPN group than the EN group. In conclusion, there was a negative correlation between the changes in the laboratory data and the hypermetabolic severity. There was an increase in the number of metabolic complications in the TPN group.

Effects of Glutamine on Hypermetabolism Reaction and Hormone Secretion After Severe Burn Injury / 中国医师杂志

Objective To study the effect of glutamine on hypermetabolism reaction and hormone secretion after severe burn injury. Methods Eighty-eight Wistar rats were inflicted with 30% total body surface area full thickness burns and randomly divided into two groups: namely burned control (B) and glutamine treatment(GLN) group. There was isonitrogenous and isocaloric intake in both groups, and rats of GLN and B groups were given glutamine and glycine at 1 0g/kg d, respectively. The following indices including the resting energy expenditure (REE), the levels of plasma cortisol, insulin and glucagon were determined. Results After burn injury, the REE, plasma cortisol,insulin and glucagons levels were significant increased in both groups. Compared with B group, the level of REE decreased and the ratio of insulin/glucagons increased in GLN group. Correlation analyses showed that REE had a negative correlation with insulin/glucagons ratio (r=-0 78,P

Ictal PET Findings of Complex Partial Status Epilepticus

We performed an 18F-fluorodeoxyglucose (FDG) position emission tomography (PET) in two patients with complex partial status epilepticus (CPSE). Ictal FDG studies usually occur by chance, because of the unpredictable nature of seizures and the short half-life of flourine-18. In addition to that, ictal PET studies are often contaminated by postictal hypometabolism due to the relatively long FDG uptake period. We experienced two patients with prolonged states of mental confusion. During the confused state, eletrophysiologic and neuroimaging studies were done to confirm the diag-nosis of CPSE. Ictal PET studies showed hypermetabolism during status epilepticus compared with interictal PET. There has been no case report about ictal PET in Korea. We present two cases of ictal PET with a review of the literature

Ictal PET Findings of Complex Partial Status Epilepticus

We performed an 18F-fluorodeoxyglucose (FDG) position emission tomography (PET) in two patients with complex partial status epilepticus (CPSE). Ictal FDG studies usually occur by chance, because of the unpredictable nature of seizures and the short half-life of flourine-18. In addition to that, ictal PET studies are often contaminated by postictal hypometabolism due to the relatively long FDG uptake period. We experienced two patients with prolonged states of mental confusion. During the confused state, eletrophysiologic and neuroimaging studies were done to confirm the diag-nosis of CPSE. Ictal PET studies showed hypermetabolism during status epilepticus compared with interictal PET. There has been no case report about ictal PET in Korea. We present two cases of ictal PET with a review of the literature

Effects of different nutrition support pathway on enterogenous hypermetabolism after severe burn injury / 肠外与肠内营养

Objective: To explore the effects of different nutrition support pathway on enterogenous hypermetabolism after severe burn injury. Methods: Eighty-eight Wistar rats were inflicted with 30% total body surface area full thickness burns and randomly divided into two groups: total parenteral nutrition (TPN) and enteral nutrition(EN) group. The following indices including the resting energy expenditure (REE), the plasma LPS, TNF and IL-1 level were determined. Results: After burn injury, the REE, TNF, LPS and IL-1 were significantly increased in two groups . Comparing with TPN group , the level of REE, TNF, LPS and IL-1 were significantly decreased in EN group (P

The Effect of Moderate Hypothermia on Infarct Size and Early Change of Regional Cerebral Glucose Uptake in Permanent Focal Cerebral Ischemia in the Rat

Using a rat model, this study examined the cerebral protective effect of moderate hypothermia and evaluated the effect on early local metabolic change of permanent focal cerebral ischemia. The middle cerebral artery(MCA) of the rat was approached subtemporally and was occluded, and its surface was cooled. Cerebral infarct size was measured at 1, 4 and 7 days after MCA occlusion in non-treated(n=27), 2-hour hypothermia(n=27) and 3-hour hypothermia(n=27) group, respectively, and regional cerebral glucose uptake(rCGU) was determined at 1 and 4 hour after MCA occlusion in the non-treated(n=8) and 3-hour hypothermia(n=8) group, respectively. Infarct size measured at 1, 4 and 7 days after MCA occlusion was 22.2%+/-4.4%, 14.3%+/-6.6%, 13.7%+/-5.3% in the non-treated group, 19.6%+/-10.0%, 12.5%+/-6.2%, 12.0%+/-6.9% in the 2-hour hypothermia group and 12.9%+/-5.6%, 8.3%+/-3.3%, 8.2%+/-2.3% in the 3-hour hypothermia group. In the 2-hour hypothermia group, no significant size reduction was seen, but in the 3-hour hypothermia group, infarct size had decreased to half of that of the non-treated group(p<0.05). This protective effect was observed untill 1 week after MCA occlusion. rCGU in the non-treated group measured at 1 hour after MCA occlusion had increased in the periphery of the ischemic core, but at 4 hours, periischemic hypermetabolism had disappeared and the area of low metabolism in the center had become larger. rCGU in the 3-hour hypothermia group measured at 1 hour after MCA occlusion(BT 26degreesC) showed a uniform decrease in all regions, supressing temporary periischemic hypermetabolism, and at 4 hours(BT 37degreesC) after occlusion, hypermetabolism was not prominent and the area of low metabolism in the center had narrowed. This study indicates that 3 hour moderate hypothermia immediately after MCA occlusion significantly reduces infarct size, and that this protective effect was associated with suppression of periischemic hypermetabolism occurring around 1 hour after MCA occlusion.

Study of mechanism of SHCDCT for brain resuscitation: Effect on hypermetabolism during reperfusion in rabbit brain / 中华麻醉学杂志

The effects of SHCDCT (selective head coolingdehydration combined therapy) on hypermetabolism, and its relation with thyroigenous hormones.The changes of glucose,phosphlipids,FT3 and TSH at 30, 180, 360 min of reperfusion following 30 min complete cerebral ischemia (four-vessel model ) in rabbits were observed.The effect of SHC (selective head cooling), DH(dehydration),SHCDCT on these changes were compared.SHC (28'C ) was induced by surface cooling methods.Compared with non-ischemia group,glouse, phospholipids decreased during reperfusoin,FT3 and TSH increased (P

A Clinical Study of Tolbutamide to Improve Hypermetabolisnl in Burn Patients / 第三军医大学学报

Relative deficiency of serum insulin and insulin resistance of tissues are the main causes of postburn hypercatabolism.In order to evaluate the clinical effects of tolbutamide to improve postburn hypermetabolism,9 burn patients were given tolbutamide and observed for 10 days after the drug had gone through animal experiments.It was found that tolbutamide could improve postburn hyper-metabolism through following ways:1.To stimulate the secretion of insulin and enhance the effect of insulin.2.To reduce the insulin resistance of tissues and promote glucose utilization of skeletal muscles.3.To inhibit the secretion of glucagon.