Enteral nutrition: what the dietitian prescribes is not what the burn patient gets!

Sudenis, Tess; Hall, Kathryn; Cartotto, Robert

Enteral nutrition (EN) is commonly interrupted in burn patients for many reasons, which leads to discrepancies between prescribed and actual EN delivery. The magnitude and origin of these discrepancies have never been well documented among burn patients. The purpose of this study was to examine differences between prescribed and actual EN delivery and to identify the specific causes of EN interruption and to quantify these. Retrospective review of patients treated between June 6, 2009 and June 6, 2012 at an adult regional American Burn Association-verified burn center who had ≥10% TBSA burns and who were prescribed EN for at least 24 hours. On postburn days (PBD) 0 to 14 the daily volume of EN prescribed by the dietitian was compared with the actual volume received by the patient. The cause and duration of interruptions to EN delivery were recorded. A total of 90 subjects, [mean (± SD) age 47 ± 18 years, 32% female, median %TBSA burn size 28, median %TBSA full-thickness burn size 11, and a 54% incidence of inhalation injury], were studied. EN was initiated at a median of 9.5 hours after burn center admission. Received calories were significantly less than prescribed calories on every study day. The median daily caloric deficit ranged between 172 and 930 kcal. The median percent of prescribed calories received each day ranged from 19% on PBD 0 to 91% on PBD 14. The mean (± SD) total duration of EN interruption was 8.9 ± 3.0 hours per day. Gradually increasing the feed rate to reach the prescribed EN goal rate ("ramping-in") was the most common cause of a discrepancy between prescribed and actual EN delivery, accounting for 35% of total discrepancy time. Interruptions for surgery accounted for 24% of total discrepancy time. Other causes of discrepancies were physician- or nurse-directed interruptions (16% of time), planned extubation (7%), feed intolerance (11%), tube malfunction (2%), bedside procedures (2%), and dressing changes (3%).Enterally fed burn patients received significantly less nutrition than prescribed. Some of the causes for discrepancies between prescribed and received EN are unavoidable, but many are not, suggesting the need for careful review and possible alteration of existing EN practices.