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Effects of Early Excision and Aggressive Enteral Feeding on Hypermetabolism, Catabolism, and Sepsis after Severe Burn

Hart, David W. MD; Wolf, Steven E. MD; Chinkes, David L. PhD; Beauford, Robert B. MD; Mlcak, Ronald P. RRT; Heggers, John P. PhD; Wolfe, Robert R. PhD; Herndon, David N. MD

Journal of Trauma-Injury Infection & Critical Care: April 2003 - Volume 54 - Issue 4 - pp 755-764
Original Articles

Background : Severe burn induces a systemic hypermetabolic response, which includes increased energy expenditure, protein catabolism, and diminished immunity. We hypothesized that early burn excision and aggressive enteral feeding diminish hypermetabolism.

Methods : Forty-six burned children were enrolled into a cohort analytic study. Cohorts were segregated according to time from burn to transfer to our institution for excision, grafting, and nutritional support. No subject had undergone wound excision or continuous nutritional support before transfer. Resting energy expenditure, skeletal muscle protein kinetics, the degree of bacterial colonization from quantitative cultures, and the incidence of burn sepsis were measured as outcome variables.

Results : Early, aggressive treatment did not decrease energy expenditure; however, it did markedly attenuate muscle protein catabolism when compared with delay in aggressive treatment. Wound colonization and sepsis were diminished in the early treatment group as well.

Conclusion : Early excision and concurrent aggressive feeding attenuate muscle catabolism and improve infectious outcomes after burn.

Severe trauma or burn induces multiple derangements in normal homeostasis. Systemic metabolism is altered, resulting in increased energy expenditure, 1 hyperdynamic circulation, 2 resetting of the hypothalamic temperature set-point, 3 altered immune function, 4 peripheral insulin resistance, 5 and skeletal muscle catabolism. 6

Clinical studies from the 1970s and 1980s suggested benefits of early burn wound excision, including decreased operative blood loss, 7 decreased length of stay, 8 fewer septic complications, 9 and decreased mortality in nonelderly burned adults. 10 These trials were from an era when parenteral and enteral nutritional support were both commonplace and feeding was generally delayed until several days after injury. Small-animal experiments from this time period intimated that early institution of enteral feeding attenuated the hypermetabolic response to burn. 11,12 The results of these well-publicized studies were widely extrapolated by trauma and burn surgeons to be applicable and beneficial to patients. The current standard of burn care has been shaped by these data and includes early institution of nutritional support as soon as hemodynamic stability is reached. However, evidence from human trials in the modern era of early burn wound excision and early aggressive enteral feeding has been conflicting regarding the metabolic consequences of these combined practice standards.

Our subjective impression was that early definitive surgical excision and early aggressive enteral feeding improve clinical outcomes. We measured metabolic parameters and recorded infectious complications in three cohorts of burn patients. These groups were segregated according to time from injury to definitive surgical treatment and institution of aggressive enteral nutritional support. Our hypotheses were that early treatment decreases energy expenditure, attenuates catabolism of both muscle mass and gross weight, and is associated with a smaller incidence of sepsis relative to delayed treatment of burn wounds.

From the Department of Surgery, The University of Texas Medical Branch, and Department of Surgery, Shriners Hospitals for Children, Galveston, Texas.

Submitted for publication October 28, 2000.

Accepted for publication January 23, 2003.

Supported by Shriners Hospital for Children grants 8660 and 8490, National Institutes of Health (NIH) training grant 2T32GM0825611, NIH center grant 1P50GM60338-01, NIH grant GM56687-02, and NIH grant M01-RR-00073 (General Clinical Research Center).

Presented at the 60th Annual Meeting of the American Association for the Surgery of Trauma, October 11–14, 2000, San Antonio, Texas.

Address for reprints: Steven E. Wolf, MD, Department of Surgery, Shriners Hospitals for Children, 815 Market Street, Galveston, TX 77550; email:

© 2003 Lippincott Williams & Wilkins, Inc.