Combustion

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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
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DIAGNOSIS LUKA BAKAR

Berdasar : 1. Luas luka bakar 2. Derajat (kedalaman) luka bakar 3. Lokalisasi 4. Penyebab

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Penetapan Luas Luka Bakar

1. 2.

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

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Rumus 9 (Rule of Nine)

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Telapak tangan = 1%

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Derajat Luka Bakar

Derajat I

Mengenai epidermis, lapisan basal masih baik, eritema, oedematus, nyeri

Derajat II

Epidermis dan dermis, bagian dasar kulit masih baik (IIa) superfisial (dangkal) : bulla, oedema, erithema, nyeri (IIb) deep (dalam) : hampir 4/30/12

Derajat Luka Bakar

Derajat III

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

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Fase Luka Bakar

Ebb-phase response hypovolemic shock:

1. 2. 3. 4. 5.

tissue perfusion metabolic rate oxygen consumption blood pressure body temperature
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Fase Luka Bakar

Flow-phase acute responses :

1. 2. 3. 4. 5. 6.

glucocorticoid glucagon catecholamin Release of cytokines, lipid mediators Production of acute-phase proteins excretion of nitrogen
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Fase Luka Bakar

Flow-phase adaptive response

1.

Hormonal response gradually disminishes hyper metabolic rate Associated with recovery Potential with restoration of body protein Wound healing depends in part on 4/30/12 njutrient intake

2. 3. 4.

5.

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

2.

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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 Urine Urea Nitrogen (UUN) excretion in grams/day has been evaluate the degree of hyper metabolism : 5=no stress, 510=mild hyper metabolism (level 1 stress), 10-15=moderate hyper metabolism (level 2), >15=severe hyper 4/30/12 metabolism (level 3)

4.

Factor to consider
1. 2. 3. 4. 5. 6.

Pre injury nutritional status Type of trauma Extent of injury Surgical finding Gastrointestinal function Enteral access option

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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: Lund & border chart
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1.

calculation

Lund & browder

2.0-3.1 mL/kg body weight/24-h/%TBSA = fluid volume

Baxter/parkland 4 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%;
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Energy
Adult
Harris benedict kebut energi (p) = 66+(13,7 x BB)+(5 x TB)(6,8 x U) x AF x FS kebut energi (w) = 665 + (9,6 x BB) + (1,8 x TB)(4,7 x U) x AF x FS
1. .

Note: meningkatkan resiko morbiditas dan mortalitas, terutama pada fase akut LB berat (overfeeding)
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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
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Energy
3.

Rule of thumb Kebut energi = 25 30 Kal/KgBB

Note: merupakan metode perhitungan yang praktis dan dapat menghindari overfeeding

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Energy
Pediatric
1.

Galveston formula Kebut energi = 1800 Kcal/m2 + 2200 Kcal/m2

2.

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

Note: polk children less then 3 yrs

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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 4/30/12

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 4/30/12 approach 15%-20% (krause), 20% fat (2-4%

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) 4/30/12

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 cant considered accurate without accounting for wound losses, the first 4 weeks may be the most reflective 4/30/12

Assessment of Energy & Protein Adequacy

1.

Formulas for predicting nitrogen losses: <10% open wound = 0.02 g nitrogen/kg/day 11-30% open wound = 0.05 g nitrogen/kg/day >31 open wound = 0.12 g nitrogen/kg/day Note: albumin levels remain depressed until major burn are healed; prealbumin, RBP, transferin helping to4/30/12 assess protein status of patient

2.

3.

Vitamin & mineral

Vitamin needs increased, but exact requirement have not been establish Recommended: Vitamin C = 500 mg twice daily (krause); 5-10 x RDA (stump) Vitamin A = 5000 IU/1000 calories of enteral nutrition (krause); 2 x RDA (stump) Sodium/potassium are corrected by 4/30/12 adjusting fluid therapy restriction

1.

2.

3.

Vitamin & mineral

4.

Depression of calcium levels may be seen in patient more than 30% TBSA (hypocalcemia : hypoalbuminemia) = supplement may necessary Hypophospathemia large volume of resuscitation & large antacid = supplement via parenterally (prevent gastric irritation) Magnesium levels loss from wound = supplement via parenterally (prevent gastric irritation) 4/30/12

5.

6.

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) Anemia usually unrelated to iron deficiency (no history) = packed red blood cell Vitamin B-com 2-3 x RDA (stump) Vitamin B12 & K diberikan mingguan 4/30/12 (stump)

8.

9. 10.

Others
11.

Use high calorie, high protein diet with 5-6 small meals & snack Avoid excesses of linoleic acid depress immunocompetence Be careful iron & zinc excess in patient with sepsis Do not alter nutritional support because watery diarrhea is likely occur for reason other than carbohydrate intolerance 4/30/12

12.

13.

14.

Beware Clinical indicator

1. 2. 3. 4.

Clinical/history Height Preburn weight Weight change Daily weight (beware of heavy exudates, edema) BMI Diet history
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5. 6. 7.

Beware Clinical indicator

Clinical/history Urine aceton, sugars Ability to chew Ability to swallow Hypovolemic shock, tachycardia, low BP, decrease urinary output Lab Albumin Transthyretin ( )
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13. 14. 15. 16.

. 1. 2.

DNI

Analgesic = GI function & appetite Antacid = change digestion process Antibiotic = leaching of sodium, potassium, magnesium, calcium & Bcom Insulin = use for stress induce hyperglicemia Interferon gamma or alpha-2b = dry mouth, stomatitis, nausea & vomiting, 4/30/12 diarrhea, abdominal pain

Refference

Stump, S.E., (2008),Nutrition and Diagnosis-Related Care, sixth edition, Philedelpia : lippincott Mahan, K., (2000), Krauses Food nutrition & Diet Therapy, USA: Saunders company

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Terimakasih

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