Manual of Clinical Nutrition Management III- 6 Copyright © 2013 Compass Group, Inc.
BURNS
Discussion
Thermal trauma results in marked hypermetabolism and hypercatabolism. Aggressive nutritional support is
required to meet metabolic demands, prevent the depletion of body energy and nitrogen stores, support
wound healing, enhance immunity, and improve survival (1-3). Energy requirements increase linearly in
proportion to burn size to a maximum of approximately twice the normal levels (1). Factors such as agitation,
pain, and heat loss during dressing changes are associated with a large increase in energy expenditure (1).
Approaches
Energy requirements in adults: Many formulas are available to determine energy requirements.
Unfortunately, many of these formulas have not been validated for the burn population (1,3). The expert
consensus is that indirect calorimetry should be used to evaluate resting energy expenditure (REE), also
refered to as resting metabolic rate (RMR), on admission to the hospital and at least once weekly until the
patient is stabilized (1,3). Indirect calorimetry should be performed late at night or early in the morning
(before daily activities) to obtain a more accurate assessment of RMR (1). In addition, indirect calorimetry is
recommended when the patient’s condition is complicated by infection, sepsis, poor wound healing, obesity,
or ventilator dependency (1). The RMR obtained from indirect calorimetry may need to be multiplied by a
factor of 1.3 (or 20% to 30%) to account for activity, physical rehabilitation, wound care, and stress of
treatments (1,4,5). This figure provides the total energy expenditure for which the clinician would base the
nutrition prescription.
If indirect calorimetry is not available, evidence based guidelines recommend using predictive equations
considering age (< 60 years or age, or > 60 years of age) and whether the patient is obese or non-obese. The
Academy currently suggests (listed in order of accuracy) Penn State (2003b), Brandi equation, Mifflin St Jeor
Equation x 1.5, and Faisey equation for use in calculating the RMR in non-obese adult critically ill patients (6).
(See Section II: “Estimation of Energy Requirements”.) The Curreri formula has also been suggested
specifically for burn patients (3). However, the Curreri equation has not been recently tested for measures of
reliability and validity (6). Clinicians should recognize the values obtained from all predictive equations are
approximate and should be used only as guidelines in predicting energy requirements in burn patients (1-3).
The clinician should be aware that the practice of adding injury and stress factors has not been validated
and may lead to the over estimation of the patient’s needs (6). Patient’s who are mechanically ventilated,
sedated or paralyzed due to severity of injury often have reduced energy needs (3). Chemical neuromuscular
paralysis decreases energy requirements of critically ill patients by as much as 30% (3).
As previously mentioned, The Curreri formula is a tool for specifically deriving the energy needs of burn
patients (7,8). The equation has been shown to overestimate the patient’s nutrition needs, particularly during
convalescence (1,3). The Curreri equation appears to be most accurate in assessing energy requirements
during the early postburn phase (7-to-10 days postburn), when energy expenditure is at its maximum (7,8).
Because the equation has not been validated in recent years, the clinician should consider using multiple
equations known to be validated (eg, Brandi equation) and compare averages with Curreri if it is used.
Curreri equation for patients aged 16 to 59 years (7):
TEE: 25 kcal x kg actual body weight + (40 kcal x % TBSABa)
aIf percent TBSAB > 50%, use a maximum value of 50%
Curreri Example: 30 year male weighing 70 kg with burns involving 50% TBSA.
TEE: 25 kcal x 70 kg + (40 kcal x 50) = 1750 kcal + 2000 kcal= 3750 kcal as total energy expenditure (9)
Source for example: Spodaryk M, Kobylarz K. The usability of harris-benedict and curreri equations in nutritional management of
thermal injuries. Annals of Burns and Fire Disasters. 2005;18:118.
Energy requirements in children: Indirect calorimetry, if available, should be used on admission to the
hospital and twice weekly thereafter until the patient is healed. The RMR should be multiplied by a factor of
1.3 (or 20% to 30%) to provide total energy needs (1,10).
For less than 30% TBSAB, use the Dietary Reference Intakes (DRI) for energy, per age group, as a starting
point to provide adequate energy intake (5). (See “Dietary Reference Intakes” in Section IA) For greater than