Intern Name: Geanella Vera-Avellan

List references you used to answer the questions at the end of this assignment.

1. What is Systemic Inflammatory Response Syndrome (SIRS) and what are the clinical
manifestations of this syndrome?
SIRS is a clinical condition that is associated with infection and non-infection sources. It
is important to assess for infection when a patient meets SIRS criteria as this infection can
often lead to sepsis or septic shock. In order to meet SIRS criteria, a patient has to meet 2
out of the following four: temperature, respiratory rate, heart rate, and white blood cells. For
temperature, a patient can have a temperature of >38C or <36C. For heart rate, >90 beats
per minute meets the criteria. For a respiratory rate of >20. And for white blood cell count,
>12,000 cells/mm3 is indicative of SIRS.

2. What is septic shock and why is it such a life-threatening condition?

Septic shock is a systemic infection with a high mortality rate. There are 2 key
identifiers for septic shock. First, the body’s response to infection results in low blood
pressure, the drop in blood pressure often leads to organ failure. Vasopressors are
needed to maintain main arterial pressure (MAP) of 65 mm Hg. Second, if serum lactate
levels are > 2 mmol/L, then the patient meets criteria for septic shock.

3. Based on the ASPEN guidelines, should ICU patients be supplemented with

glutamine? Why or why not?
Based on the 2016 ASPEN guidelines, it is not suggested to use enteral glutamine to
adult patients in the ICU. In the randomized control studies that used enteral glutamine
for patients with critical illness, there was no significant beneficial effect on mortality,
infection or length of stay (LOS) by providing glutamine to enteral formulas.

4. When do the ASPEN guidelines recommend starting severely septic patients on

enteral nutrition?
ASPEN guidelines recommendations on when to start EN for severely septic patients is
“within 24-48 hours of the septic shock diagnosis and as soon as resuscitation is
complete and the patient is hemodynamically stable”, which is having a MAP > 65
mmHg.

5. What is Intracranial Pressure (ICP) and what is considered a normal range?

What is Cerebral Perfusion Pressure (CPP) and how are the ICP and CPP related?

ICP is a rise in the pressure around the brain. Normal range of ICP is defined as 5 to 15
mmHg (7.5-20 cm H2O). An increased intracranial pressure is defined as cerebrospinal
fluid pressure (CSF) > 15 mmHg. Any increase in ICP can increase the risk of stroke
and/or change in tissue perfusion. CPP is the pressure of the blood entering the brain. A
CPP target of 60-80 mmHg is needed for effective perfusion. Blood pressure (BP) as
 well as ICP affect CPP. if BP drops and ICP increases, the blood flow to the brain may
be limited. The relationship between CPP and ICP is that CPP is calculated by the
differences between Mean Arterial Pressure (MAP) and ICP.

6. What is mannitol and how is it used to manage Traumatic Brain Injury patients?

Mannitol is a sugar alcohol that has been studied to manage traumatic brain injury (TBI)
by reducing brain swelling in patients with this condition. However, recent studies have
shown that mannitol, in prolonged dosage, may accumulate in the brain due to the
reverse osmotic shift that happens causing brain osmolarity and as a result increasing
ICP.

7. Should immune-modulating enteral formulas be used in patients with a Traumatic

Brain Injury? Provide rationale for your answer.
Based on the ASPEN guidelines of 2016, immune modulating enteral formulations
containing arginine, EPA, DHA, glutamine and nucleic acid should be reserved for
patients with TBI instead of patients in the MICU. ASPEN also suggests the use of either
arginine-containing immune-modulating formulas or EPA/DHA supplement with standard
enteral formula with TBI patients. The rationale behind is that these immune-modulating
formulas may potentially decrease infections, but only 1 small trial in an adult population
showed these results; therefore the evidence is low.

8. What is a ventriculostomy and why is it used?

A ventriculostomy is a procedure that allows for removal of excess fluid in the
cerebrospinal fluid (CSF) that has been blocked due to a possible hemorrhage. This
helps to decrease the pressure in the brain, and drains the blood in fluid spaces, blood
reabsorbs and circulation of CSF can start up again.

9. What are allografts, autografts and cultured epithelial autografts as related to skin
grafting?
An autograft is a type of surgery that uses tissue from your own body, while an allograft
is a piece of tissue that is transplanted from one person to another. With the
advancement of technology, cultured epithelial autografts (CEAs) are a type of graft that
provide a permanent skin replacement for patients who have suffered from full thickness
burns by using the patient’s own skin cells and placing them in an incubator to grow.

What are the advantages and disadvantages of each?

Advantages of allografts:
- Surgical time and hospital stay may be shorter than the other types of graft
- Less painful initial recovery
- No donor site morbidity
Disadvantages of allografts:
- Concerns about disease transmission
- Highly costly
- Slower graft incorporation
Advantages of autografts:
- Provides essential, growth factors for healing and bone regeneration
- Less risk of disease transmission
- No risk of rejection of graft
Disadvantages of autografts:
- Initial recovery is longer and more painful
- Patients may suffer from tissue morbidity
- Surgical wound problems (ie: infection)
Advantages of CEAs:
- No rejection of the graft material
- Permanent skin replacement for full thickness burns
- Does not require a second skin wound
Disadvantages of CEAs:
- Long production time
- Highly costly
- Time consuming and labor intensive

10. Give a brief description of the anatomy of the skin and the skin’s functions.
The skin is the largest organ in the human body and it serves to provide a soft outer
covering to the human body.
The skin has 3 layers: epidermis, dermis, and hypodermis.
The epidermis is the most outer skin layer. It is the protective layer. It’s composed of
melanocytes, squamous, and basal cells.
The dermis is the layer where the connective tissue is found. This is also where hair
follicles, sweat glands, sebaceous glands, lymph and blood vessels are found. This layer
provides a sense of touch and heat.
The hypodermis is the layer found directly below the dermis which connects the bones
and muscles. It consists of connective and adipose tissue which serves as fat storage
and provides insulation.
The main functions of the skin include: sensation, protection, storage, thermoregulation
Sensation allows us to have nerves respond to temperature, pressure and pain. Our skin
protects from external pathogens by acting as a layer. Our skin can also store water and
lipids for other physiological functions. Lastly, our skin can thermoregulate by dilating
blood vessels and secreting sweat from sweat glands.

11. What are the differences between 1 st, 2nd, and 3rd degree burns? How would the
degree of the burn impact the MNT recommendations, specifically regarding energy and
protein needs?
Burns are classified based on the depth and the mechanism of which it happened. First
degree burns are classified as superficial because it affects only the epidermis (the outer
layer of skin). Second degree burns are classified as partial thickness because it affects
the epidermis and part of the dermis layer of skin. Lastly, third degree burns are
classified as full thickness because it destroys the epidermis and dermis, and may also
damage bones, muscles, and tendons.
MNT recommendations would vary for each degree of burn. Adult patients with burns
should receive 25 kcal/kg/day plus 40 kcal/%TBSA/day. Patients with large burns should
receive protein in the range of 1.5-2.0 g/kg/day.
12. Based on ASPEN guidelines, when should nutrition support be initiated in a burn
injury patient?

Based on ASPEN guidelines, nutrition support should be initiated within 4-6 hours of
injury in a burn patient.

13. There are several ways to determine the extent or Total Body Surface Area (TBSA)
of a burn.
Briefly describe each of the following and when each would be appropriate to use:
a. Rule of Palms
A method used to estimate the TBSA by using the patient’s palmar surface
including their fingers, which amounts to 1% TBSA. This helps calculate a
patient’s fluid resuscitation needs. This method is best used for minor or
scattered burns.

b. Rule of Nines
A method that assesses the percentage of burn and is used to determine the total
% TBSA of the burn. This technique divides the body into percentages of 9. This
method is best used for larger burn areas.

c. Lund and Browder Chart

A gold-standard technique that accounts for variation in body shape with age. It
can be used for adult and pediatric populations. This chart considers full
thickness and partial thickness burns.

14. What are the major electrolytes outside of and inside of the cell? What controls the
high amounts of sodium kept in the ECF and the relatively high amounts of potassium
kept in the ICF?

The major electrolytes outside of the cell are: sodium, calcium, chloride, and
bicarbonate.
The major electrolytes inside of the cell are: potassium, magnesium, phosphorus and
proteins.
What controls the high amounts of sodium kept in the ECF is the blood plasma since the
concentration in the blood plasma is the same as the sodium concentration in the ECF or
interstitial fluid. The high amounts of potassium in ICF are controlled by the Na+ and K+
Pump Cycle.

15. What is the equation for calculating a fluid deficit? How fast should free water be
repleted?
The fluid deficit equation is as follows:
 Free Water Deficit = TBW x (Measured Na/Ideal Na -1); where TBW is total body water,
which is equal to= correction factor x weight in kg.

Free water should be repleted based on the acuity of the issue. If hypernatremia is acute
(<48 hours), the goal is to lower Na+ levels to 145 mmol/L within 24 hours. If
hypernatremia is chronic (>48 hours), the goal is to lower Na+ levels to a max of 10
mEq/L in 24 hours (0.5 mEq/L/hour).

What are the consequences of repleting water too quickly?

It is critical to not exceed this rate as it can lead to cerebral edema. In addition, it is
important to re-check Na+ levels every 2 hours.

16. What is Syndrome of Inappropriate Antidiuretic Hormone (SIADH)? In what type of

patient is this most likely to be seen? How will it impact the MNT you provide to the
patient?

SIADH is a condition in which a person makes too much antidiuretic hormone (ADH).
This condition is most likely to be seen in older patients who are hospitalized with heart
conditions or with diseased hypothalamus, which are hormones like ADH.
As part of the MNT, patients with SIADH may need to be on a fluid restriction due to
symptoms of hyponatremia. A high protein diet intervention should be placed for patients
with SIADH since a higher protein intake can lead to an increase in urinary output, and
therefore, improvement in hyponatremia symptoms.

Case Study

Jamie Lannister is a 43 year old male who was injured returning to King’s Landing after
defeating the Tyrell army at Highgarden. Witnesses report Jamie was burned by Drogon,
Daenerys Targaryen’s largest dragon. For more information about these characters, you can
visit https://en.wikipedia.org/wiki/Jaime_Lannister
He was transported by his assistant, Bronn, back to King’s Landing and was found to have
75% TBSA burn with 60% full thickness burns.
He was placed on a mechanical ventilator, IV fluids were started and a NG tube was inserted
for low intermittent suctioning. He was then transferred to the burn unit. (King’s Landing has
very advanced medical care!).

The RD visited the patient the next day and began her nutritional assessment.
Pertinent findings:
Ht: 6’2””, Wt: 195# (dry weight), IV fluids of lactated ringers running at 100ml/hr. I/O for past
24 hours: 2400/1520 (720ml urine, 800ml NG tube), hypoactive bowel sounds, abdomen soft
and non-tender.
 1. Calculate the patient’s calorie needs using the Curreri Formula and another
appropriate formula, and compare the results.
The Curreri formula: (25 x body weight (kg) + 40 x % BSA burned)
(25 x 88.6) + (40 x 75 %BSA)
2215 + 3000
5215 kcals

Ireton-Jones formula: 1925-10(age) + 5W + 281(1) + 292(1) + 851(1)

1925 - 10(43) + 5(88.6) + 281 + 292 + 851
1925 - 430 + 443 + 281 + 292 + 851
Ireton-Jones formula = 4222 kcals

2. Calculate the patient’s protein needs.

1.5-2.0 g/kg/daily
88.6 kg x 1.5 g/kg = 133 g protein
88.6 kg x 2.0 g/kg = 177 g protein

3. Calculate the patient’s fluid needs using the Parkland formula.

Parkland Formula: 4 mL x BSA% x kg
: 4 mL x 75 BSA% x 88.6 kg
: 26,580 mL of LR infusion
1st 8 hours of LR infusion for fluid resuscitation
26580 mL / 2= 13290 mL
13290 mL / 8 hours = 1661 mL/hr

Other ½ of LR infusion to run for the remaining 16 hours

13290 mL / 16 hours = 831 mL/hr

4. Write a PES statement for this patient.

Increased nutrient (energy/protein) needs related to increased physiological demand

for needs as evidenced by catabolic state of 75% TBSA burn injury with 60% full
thickness burn

5. What are your MNT recommendations for this patient? Do you think extra
vitamin/mineral supplements are needed? Why or why not?

I would recommend a high protein, high caloric formula for enteral feeding with
protein modular to meet the higher end of protein requirement. It is important to not
overfeed and control hyperglycemia. Therefore, enteral feeding should be started at
a trophic rate, and increase while monitoring tolerance over the next few days of
initiation. I would recommend starting with vitamin C, along with zinc supplementation
 to aid in collagen synthesis and promote optimal wound healing. I would also
recommend calcium and vitamin D supplementation since burn patients are more
susceptible to fractures. Other vitamins such as vitamin E and trace minerals
including selenium and copper have shown to provide some improvement in patient
outcome; however, the quality of evidence is low based on ASPEN guidelines. I
would like to mention that glutamine supplementation for burn patients has been
studied and shows promising results such as reduction in hospital mortality and
improves overall clinical outcomes and has been recommended by the ESPEN
guidelines; however, ASPEN has not made applicable recommendations on
glutamine application to this critically ill group of patients, thus, more studies need to
confirm the effects of glutamine in burn patients.

Resources:

“Determining Total Body Surface Area.” Minnesota Dept. of Health,

www.health.state.mn.us/communities/ep/surge/burn/tbsa.html.

“Stanford Children's Health.” Stanford Children's Health - Lucile Packard Children's Hospital
Stanford, www.stanfordchildrens.org/en/topic/default?id=anatomy-of-the-skin-85-
P01336.

“What Is Cerebral Perfusion Pressure?” University of Iowa Hospitals & Clinics, 10 Oct. 2018,
uihc.org/health-topics/what-cerebral-perfusion-pressure.

Garg, Sunil Kumar. “Hyponatremia Management in Critically Ill: Food (Protein) for Thought.”
Indian Journal of Critical Care Medicine : Peer-Reviewed, Official Publication of
Indian Society of Critical Care Medicine, Medknow Publications & Media Pvt Ltd,
Mar. 2015, www.ncbi.nlm.nih.gov/pmc/articles/PMC4366925/.

McClave, Stephen A., et al. “Guidelines for the Provision and Assessment of Nutrition
Support Therapy in the Adult Critically Ill Patient.” American Society for Parenteral
and Enteral Nutrition, John Wiley & Sons, Ltd, 14 Jan. 2016,
aspenjournals.onlinelibrary.wiley.com/doi/full/10.1177/0148607115621863.

Mistry, Hema et al. “Autograft or allograft for reconstruction of anterior cruciate ligament: a
health economics perspective.” Knee surgery, sports traumatology, arthroscopy :
official journal of the ESSKA vol. 27,6 (2019): 1782-1790. doi:10.1007/s00167-019-
05436-z

Rana, Sumegha, and R.G Blaxa. Role of Glutamine Supplementation in Management of

Burn Patients. IOSR Journal of Dental and Medical Sciences (IOSR-JDMS), July
2018, www.iosrjournals.org/iosr-jdms/papers/Vol17-issue7/Version-
13/J1707135760.pdf.

Rangel-Castilla, Leonardo, et al. “Management of Intracranial Hypertension.” Neurologic

Clinics, U.S. National Library of Medicine, May 2008,
 www.ncbi.nlm.nih.gov/pmc/articles/PMC2452989/#:~:text=For%20the%20purpose%
20of%20this,20%20mm%20Hg%20%5B5%5D.

Wakai, Abel et al. “Mannitol for acute traumatic brain injury.” The Cochrane database of
systematic reviews vol. 2013,8 CD001049. 5 Aug. 2013,
doi:10.1002/14651858.CD001049.pub5