BACKGROUND:
Most of deaths in burn patient are related with sepsis from wound infection or inhalation injury. Thus, nutrition support is crucial to facilitate wound healing and prevent infection especially in diabetic patient.
CLIENT HISTORY:
A-60-year-old Indian man diagnosed with Alleged 2nd degree burn 8.5% over left forearm bilateral upper and lower limb. He has underlying of Diabetes Mellitus and Hypertension. Referred to dietitian on post traumatic day 3 (PTD3) for nutrition support.
ASSESSMENT:
BMI was normal. Laboratory data revealed normal result except for low albumin (Alb), high white blood cell (WBC) and poor glycemic control. Nutrient intake from oral were 1120kcal, 47.5g protein (NPC:N = 122:1 ratio), 90g carbohydrate (CHO), 57g fat and 10.8g Glutamine, not achieved requirement but achieved adequate fluid intake.
NUTRITION DIAGNOSIS:
Inadequate oral intake related to increased nutrients needs as evidenced by diet history (energy: 1120kcal as compared to requirement 2000kcal; protein intake: 47.5g as compared to requirement 100g)
OBJECTIVE & PRESCRIPTION:
Objectives: To achieve adequate energy and protein intake, to attain good glycemic control, to maintain adequate fluid intake, to prevent infection and facilitate wound healing.
Prescription: Energy; 2000kcal (Toronto formula), 100g protein (1.5g/kg) (NPC: N= 100:1 ratio), 20.7g glutamine (0.3g/kg), 250g CHO (<5g/kg), 66.67g fat (30%), 2.4L fluid maintenance.
OUTCOME & FOLLOW-UP:
Follow up was continued until PTD17. Laboratory data showed improving trend of albumin (20 to 29mmol/l), WBC (18.1 to 5.3mmol/l) and good glycemic control. No infection was noted and wound condition has improved (formation of scab and scar). Nutrient intakes from oral were improving from 1120 to 1964kcal, 47.5 to 102g protein (NPC: N=95:1 ratio), 90 to 210g CHO, 57 to 68g fat, 10.3 to 21.3g glutamine and 2.2L fluid intake, achieved requirement as prescribed. Glutamine-enriched with low Glycemic Index enteral formula was given until PTD14 and was substituted with diabetic formula until PTD17.
DISCUSSION:
Similar practice by Ross Tilley Burn Centre, Canada by prescribing 10g glutamine, two to four times daily depending on estimated requirements (0.3-0.5g/kg/day) effective to prevent infection and speed up wound recovery.
LEARNING POINTS:
• Glutamine becomes conditionally essential after burn injury
• Glutamine facilitate wound healing and decreasing rates of infection
• Glutamine supplementation was effective until 14-21days post burn
