ESPEN endorsed recommendations: Nutritional therapy in major burns

doi:10.1016/J.CLNU.2013.02.012

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ESPEN endorsed recommendations: Nutritional therapy in major burns

Journal Article•DOI•

ESPEN endorsed recommendations: Nutritional therapy in major burns

Anne-Françoise Rousseau¹, Marie Reine Losser, Carole Ichai, Mette M. Berger²•Institutions (2)

University of Liège¹, University Hospital of Lausanne²

01 Aug 2013-Clinical Nutrition (Elsevier)-Vol. 32, Iss: 4, pp 497-502

TL;DR: The nutritional therapy in major burns has evidence-based specificities that contribute to improve clinical outcome.

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About: This article is published in Clinical Nutrition.The article was published on 2013-08-01. It has received 246 citations till now. The article focuses on the topics: Medical nutrition therapy.

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Journal Article•DOI•

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.)

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Nilesh M. Mehta¹, Heather E. Skillman¹, Sharon Y. Irving², Jorge A. Coss-Bu³, Sarah Vermilyea⁴, Elizabeth Anne Farrington¹, Liam McKeever⁵, Amber M. Hall¹, Praveen S. Goday⁶, Carol L. Braunschweig⁵ - Show less +6 more•Institutions (6)

Boston Children's Hospital¹, University of Pennsylvania², Baylor College of Medicine³, Cincinnati Children's Hospital Medical Center⁴, University of Illinois at Chicago⁵, Medical College of Wisconsin⁶

01 May 2009-Journal of Parenteral and Enteral Nutrition

TL;DR: The guidelines reiterate the importance of nutrition assessment-particularly, the detection of malnourished patients who are most vulnerable and therefore may benefit from timely intervention and there is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake.

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Abstract: This document represents the first collaboration between 2 organizations-the American Society for Parenteral and Enteral Nutrition and the Society of Critical Care Medicine-to describe best practices in nutrition therapy in critically ill children. The target of these guidelines is intended to be the pediatric critically ill patient (>1 month and 2-3 days in a PICU admitting medical, surgical, and cardiac patients. In total, 2032 citations were scanned for relevance. The PubMed/MEDLINE search resulted in 960 citations for clinical trials and 925 citations for cohort studies. The EMBASE search for clinical trials culled 1661 citations. In total, the search for clinical trials yielded 1107 citations, whereas the cohort search yielded 925. After careful review, 16 randomized controlled trials and 37 cohort studies appeared to answer 1 of the 8 preidentified question groups for this guideline. We used the GRADE criteria (Grading of Recommendations, Assessment, Development, and Evaluation) to adjust the evidence grade based on assessment of the quality of study design and execution. These guidelines are not intended for neonates or adult patients. The guidelines reiterate the importance of nutrition assessment-particularly, the detection of malnourished patients who are most vulnerable and therefore may benefit from timely intervention. There is a need for renewed focus on accurate estimation of energy needs and attention to optimizing protein intake. Indirect calorimetry, where feasible, and cautious use of estimating equations and increased surveillance for unintended caloric underfeeding and overfeeding are recommended. Optimal protein intake and its correlation with clinical outcomes are areas of great interest. The optimal route and timing of nutrient delivery are areas of intense debate and investigations. Enteral nutrition remains the preferred route for nutrient delivery. Several strategies to optimize enteral nutrition during critical illness have emerged. The role of supplemental parenteral nutrition has been highlighted, and a delayed approach appears to be beneficial. Immunonutrition cannot be currently recommended. Overall, the pediatric critical care population is heterogeneous, and a nuanced approach to individualizing nutrition support with the aim of improving clinical outcomes is necessary.

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2,947 citations

Cites background or result from "ESPEN endorsed recommendations: Nut..."

...In a subset of patients from the EPaNiC study for whom there was an absolute contraindication to the use of EN (such as bowel in discontinuity), Casaer et al showed that those patients for whom use of PN was started on ICU day 3 had worse infectious morbidity and were less likely to be discharged alive than those patients for whom PN was started instead on day 8.240 In a large RCT involving critically ill patients with a perceived contraindication to EN, use of PN within 24 hours of admission showed minimal benefit over STD where no nutrition therapy was provided (shorter duration of mechanical ventilation, WMD = −0.47 days; 95% CI, −0.82 to −0.11; P = .01), with no difference between groups with regard to infection, organ failure, total complications, or mortality.242 Because of the wide variation of nutrition risk in these populations, clinical judgment should be used to determine those less likely to benefit from PN....
[...]
...Although refeeding syndrome can occur with EN, the risk is higher with initiation of PN....
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...5–2 g of protein/kg/d for patients with burn injury.(389,396)...
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...Trauma patients provided IVFE-free PN over the first 10 days of hospitalization had a significant reduction in infectious morbidity (pneumonia, P = .05; catheter-related sepsis, P = .04) (Figure 10),266,268 decreased hospital and ICU LOS (P = .03 and P = .02), and shorter duration of mechanical ventilation (P = .01) compared with those receiving SO-based IVFE-containing PN.268 However, the IVFE-free PN formulation was hypocaloric (21 kcal/kg/d vs 28 kcal/kg/d) as a result of leaving off the fat.268 A similar study comparing a hypocaloric IVFE-free regimen (1000 total kcal/d and 70 g of protein/d) versus an SO-based IVFE standard admixture (25 kcal/kg/d and 1.5 g of protein/d) found no significant differences in infectious complications, hospital LOS, or mortality.266 This finding was confirmed by a large observational study that reviewed outcomes in patients who received PN for ≥5 days in multi-international ICUs....
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...When these alternative IVFEs (SMOF [soybean oil, MCT, olive oil, and fish oil emulsion], MCT, OO, and FO) become available in the United States, based on expert opinion, we suggest that their use be considered in the critically ill patient who is an appropriate candidate for PN. Rationale: In the United States at the present time, the choice of IVFE for PN is limited to a soy-based 18-carbon omega-6 fatty acid preparation....
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Journal Article•DOI•

Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.).

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Robert G. Martindale¹, Stephen A. McClave², Vincent W. Vanek¹, Mary McCarthy, Pamela R. Roberts, Beth Taylor³, Juan B. Ochoa, Lena M. Napolitano, Gail Cresci - Show less +5 more•Institutions (3)

Oregon Health & Science University¹, University of Louisville², Washington University in St. Louis³

01 May 2009-Critical Care Medicine

TL;DR: These guidelines offer basic recommendations that are supported by review and analysis of the current literature, other national and international guidelines, and a blend of expert opinion and clinical practicality that are directed toward generalized patient populations.

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Abstract: A.S.P.E.N. and SCCM are both nonprofit organizations composed of multidisciplinary healthcare professionals. The mission of A.S.P.E.N. is to improve patient care by advancing the science and practice of clinical nutrition and metabolism. The mission of SCCM is to secure the highest quality care for all critically ill and injured patients. Guideline Limitations: These A.S.P.E.N.−SCCM Clinical Guidelines are based on general conclusions of health professionals who, in developing such guidelines, have balanced potential benefits to be derived from a particular mode of medical therapy against certain risks inherent with such therapy. However, practice guidelines are not intended as absolute requirements. The use of these practice guidelines does not in any way project or guarantee any specific benefit in outcome or survival. The judgment of the healthcare professional based on individual circumstances of the patient must always take precedence over the recommendations in these guidelines. The guidelines offer basic recommendations that are supported by review and analysis of the current literature, other national and international guidelines, and a blend of expert opinion and clinical practicality. The population of critically ill patients in an intensive care unit (ICU) is not homogeneous. Many of the studies on which the guidelines are based are limited by sample size, patient heterogeneity, variability in disease severity, lack of baseline nutritional status, and insufficient statistical power for analysis. Periodic Guideline Review and Update: This particular report is an update and expansion of guidelines published by A.S.P.E.N. and SCCM in 2009 (1). Governing bodies of both A.S.P.E.N. and SCCM have mandated that these guidelines be updated every three to five years. The database of randomized controlled trials (RCTs) that served as the platform for the analysis of the literature was assembled in a joint “harmonization process” with the Canadian Clinical Guidelines group. Once completed, each group operated separately in their interpretation of the studies and derivation of guideline recommendations (2). The current A.S.P.E.N. and SCCM guidelines included in this paper were derived from data obtained via literature searches by the authors through December 31, 2013. Although the committee was aware of landmark studies published after this date, these data were not included in this manuscript. The process by which the literature was evaluated necessitated a common end date for the search review. Adding a last-minute landmark trial would have introduced bias unless a formalized literature search was re-conducted for all sections of the manuscript. Target Patient Population for Guideline: The target of these guidelines is intended to be the adult (≥ 18 years) critically ill patient expected to require a length of stay (LOS) greater than 2 or 3 days in a medical ICU (MICU) or surgical ICU (SICU). The current guidelines were expanded to include a number of additional subsets of patients who met the above criteria, but were not included in the previous 2009 guidelines. Specific patient populations addressed by these expanded and updated guidelines include organ failure (pulmonary, renal, and liver), acute pancreatitis, surgical subsets (trauma, traumatic brain injury [TBI], open abdomen [OA], and burns), sepsis, postoperative major surgery, chronic critically ill, and critically ill obese. These guidelines are directed toward generalized patient populations but, like any other management strategy in the ICU, nutrition therapy should be tailored to the individual patient. Target Audience: The intended use of these guidelines is for all healthcare providers involved in nutrition therapy of the critically ill, primarily physicians, nurses, dietitians, and pharmacists. Methodology: The authors compiled clinical questions reflecting key management issues in nutrition therapy. A committee of multidisciplinary experts in clinical nutrition composed of physicians, nurses, pharmacists, and dietitians was jointly convened by the two societies.

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1,734 citations

Cites background or result from "ESPEN endorsed recommendations: Nut..."

...In a subset of patients from the EPaNiC study for whom there was an absolute contraindication to the use of EN (such as bowel in discontinuity), Casaer et al showed that those patients for whom use of PN was started on ICU day 3 had worse infectious morbidity and were less likely to be discharged alive than those patients for whom PN was started instead on day 8.240 In a large RCT involving critically ill patients with a perceived contraindication to EN, use of PN within 24 hours of admission showed minimal benefit over STD where no nutrition therapy was provided (shorter duration of mechanical ventilation, WMD = −0.47 days; 95% CI, −0.82 to −0.11; P = .01), with no difference between groups with regard to infection, organ failure, total complications, or mortality.242 Because of the wide variation of nutrition risk in these populations, clinical judgment should be used to determine those less likely to benefit from PN....
[...]
...Although refeeding syndrome can occur with EN, the risk is higher with initiation of PN....
[...]
...5–2 g of protein/kg/d for patients with burn injury.(389,396)...
[...]
...Trauma patients provided IVFE-free PN over the first 10 days of hospitalization had a significant reduction in infectious morbidity (pneumonia, P = .05; catheter-related sepsis, P = .04) (Figure 10),266,268 decreased hospital and ICU LOS (P = .03 and P = .02), and shorter duration of mechanical ventilation (P = .01) compared with those receiving SO-based IVFE-containing PN.268 However, the IVFE-free PN formulation was hypocaloric (21 kcal/kg/d vs 28 kcal/kg/d) as a result of leaving off the fat.268 A similar study comparing a hypocaloric IVFE-free regimen (1000 total kcal/d and 70 g of protein/d) versus an SO-based IVFE standard admixture (25 kcal/kg/d and 1.5 g of protein/d) found no significant differences in infectious complications, hospital LOS, or mortality.266 This finding was confirmed by a large observational study that reviewed outcomes in patients who received PN for ≥5 days in multi-international ICUs....
[...]
...When these alternative IVFEs (SMOF [soybean oil, MCT, olive oil, and fish oil emulsion], MCT, OO, and FO) become available in the United States, based on expert opinion, we suggest that their use be considered in the critically ill patient who is an appropriate candidate for PN. Rationale: In the United States at the present time, the choice of IVFE for PN is limited to a soy-based 18-carbon omega-6 fatty acid preparation....
[...]

Journal Article•DOI•

ESPEN guideline on clinical nutrition in the intensive care unit

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Pierre Singer¹, Annika Reintam Blaser², Mette M. Berger³, Waleed Alhazzani⁴, Philip C. Calder⁵, Michael P Casaer⁶, Michael Hiesmayr, Konstantin Mayer, J.C. Montejo, Claude Pichard⁷, Jean-Charles Preiser⁸, Arthur R. H. van Zanten, Simon Oczkowski⁴, Wojciech Szczeklik⁹, Stephan C. Bischoff¹⁰ - Show less +11 more•Institutions (10)

Rabin Medical Center¹, University of Tartu², University of Lausanne³, McMaster University⁴, University Hospital Southampton NHS Foundation Trust⁵, The Catholic University of America⁶, Geneva College⁷, Université libre de Bruxelles⁸, Jagiellonian University Medical College⁹, University of Hohenheim¹⁰

01 Feb 2019-Clinical Nutrition

TL;DR: Particular conditions frequently observed in intensive care such as patients with dysphagia, frail patients, multiple trauma patients, abdominal surgery, sepsis, and obesity are discussed to guide the practitioner toward the best evidence based therapy.

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1,474 citations

Cites result from "ESPEN endorsed recommendations: Nut..."

...This has been confirmed in the latest meta-analysis [210,211], and is included in the specific ESPEN burn guidelines [212]....
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Journal Article•DOI•

The metabolic stress response to burn trauma: current understanding and therapies.

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Craig Porter¹, Craig Porter², Ronald G. Tompkins³, Celeste C. Finnerty¹, Celeste C. Finnerty², Labros S. Sidossis⁴, Oscar E. Suman¹, Oscar E. Suman², David N. Herndon², David N. Herndon¹ - Show less +6 more•Institutions (4)

Shriners Hospitals for Children - Galveston¹, University of Texas Medical Branch², Harvard University³, Rutgers University⁴

01 Oct 2016-The Lancet

TL;DR: This article aims to distill the current knowledge pertaining to the stress response to burn trauma, highlighting recent developments and important knowledge gaps that need to be pursued in order to develop novel therapeutic strategies which improve outcomes in burn survivors.

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204 citations

Journal Article•DOI•

Nutrition and metabolism in burn patients

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Audra T. Clark¹, Jonathan B. Imran¹, Tarik D. Madni¹, Steven E. Wolf¹•Institutions (1)

University of Texas Southwestern Medical Center¹

17 Apr 2017-Burns & Trauma

TL;DR: There is no consensus regarding the optimal timing, route, amount, and composition of nutritional support for burn patients, but most clinicians advocate for early enteral nutrition with high-carbohydrate formulas.

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Abstract: Severe burn causes significant metabolic derangements that make nutritional support uniquely important and challenging for burned patients. Burn injury causes a persistent and prolonged hypermetabolic state and increased catabolism that results in increased muscle wasting and cachexia. Metabolic rates of burn patients can surpass twice normal, and failure to fulfill these energy requirements causes impaired wound healing, organ dysfunction, and susceptibility to infection. Adequate assessment and provision of nutritional needs is imperative to care for these patients. There is no consensus regarding the optimal timing, route, amount, and composition of nutritional support for burn patients, but most clinicians advocate for early enteral nutrition with high-carbohydrate formulas. Nutritional support must be individualized, monitored, and adjusted throughout recovery. Further investigation is needed regarding optimal nutritional support and accurate nutritional endpoints and goals.

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121 citations

Cites background from "ESPEN endorsed recommendations: Nut..."

...The metabolic rate of these patients can be greater than twice the normal rate, and this response can last for more than a year after the injury [1, 2]....
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...severely burned patients (Table 2) [2, 75, 86, 87]....
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...Because of this, nutritional support should ideally be initiated within 24 h of injury via an enteral route [2, 19]....
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Journal Article•DOI•

ESPEN Guidelines on Parenteral Nutrition: intensive care.

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Pierre Singer, Mette M. Berger, Greet Van den Berghe, Gianni Biolo, Philip C. Calder, Alastair Forbes, Richard D. Griffiths, Georg Kreyman, Xavier Leverve, Claude Pichard - Show less +6 more

01 Apr 2006-Clinical Nutrition

TL;DR: The authors will present not only the evidence available regarding the indications for PN, its implementation, the energy required, its possible complementary use with enteral nutrition, but also the relative importance of the macro- and micronutrients in the formula proposed for the critically ill patient.

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1,698 citations

Journal Article•DOI•

Increased mortality associated with growth hormone treatment in critically ill adults.

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Jukka Takala, Esko Ruokonen¹, Nigel R. Webster, Michael S. Nielsen², Durk F. Zandstra, Guy Vundelinckx, Charles J. Hinds³ - Show less +3 more•Institutions (3)

University of Eastern Finland¹, Southampton General Hospital², St Bartholomew's Hospital³

09 Sep 1999-The New England Journal of Medicine

TL;DR: In patients with prolonged critical illness, high doses of growth hormone are associated with increased morbidity and mortality.

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Abstract: Background The administration of growth hormone can attenuate the catabolic response to injury, surgery, and sepsis. However, the effect of high doses of growth hormone on the length of stay in intensive care and in the hospital, the duration of mechanical ventilation, and the outcome in critically ill adults who are hospitalized for long periods is not known. Methods We carried out two prospective, multicenter, double-blind, randomized, placebo-controlled trials in parallel involving 247 Finnish patients and 285 patients in other European countries who had been in an intensive care unit for 5 to 7 days and who were expected to require intensive care for at least 10 days. The patients had had cardiac surgery, abdominal surgery, multiple trauma, or acute respiratory failure. The patients received either growth hormone (mean [±SD] daily dose, 0.10±0.02 mg per kilogram of body weight) or placebo until discharge from intensive care or for a maximum of 21 days. Results The in-hospital mortality rate was higher...

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1,085 citations

Journal Article•DOI•

Intensive insulin therapy and mortality among critically ill patients: a meta-analysis including NICE-SUGAR study data

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Donald E. G. Griesdale¹, Russell J. de Souza, Rob M. van Dam, Daren K. Heyland, Deborah J. Cook, Atul Malhotra, Rupinder Dhaliwal, William R. Henderson, Dean R. Chittock, Simon Finfer, Daniel Talmor - Show less +7 more•Institutions (1)

University of British Columbia¹

14 Apr 2009-Canadian Medical Association Journal

TL;DR: Intensive insulin therapy significantly increased the risk of hypoglycemia and conferred no overall mortality benefit among critically ill patients, but this therapy may be beneficial to patients admitted to a surgical ICU.

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Abstract: Background: Hyperglycemia is associated with increased mortality in critically ill patients. Randomized trials of intensive insulin therapy have reported inconsistent effects on mortality and increased rates of severe hypoglycemia. We conducted a meta-analysis to update the totality of evidence regarding the influence of intensive insulin therapy compared with conventional insulin therapy on mortality and severe hypoglycemia in the intensive care unit (ICU). Methods: We conducted searches of electronic databases, abstracts from scientific conferences and bibliographies of relevant articles. We included published randomized controlled trials conducted in the ICU that directly compared intensive insulin therapy with conventional glucose management and that documented mortality. We included in our meta-analysis the data from the recent NICE-SUGAR (Normoglycemia in Intensive Care Evaluation — Survival Using Glucose Algorithm Regulation) study. Results: We included 26 trials involving a total of 13 567 patients in our meta-analysis. Among the 26 trials that reported mortality, the pooled relative risk (RR) of death with intensive insulin therapy compared with conventional therapy was 0.93 (95% confidence interval [CI] 0.83–1.04). Among the 14 trials that reported hypoglycemia, the pooled RR with intensive insulin therapy was 6.0 (95% CI 4.5–8.0). The ICU setting was a contributing factor, with patients in surgical ICUs appearing to benefit from intensive insulin therapy (RR 0.63, 95% CI 0.44–0.91); patients in the other ICU settings did not (medical ICU: RR 1.0, 95% CI 0.78–1.28; mixed ICU: RR 0.99, 95% CI 0.86–1.12). The different targets of intensive insulin therapy (glucose level ≤ 6.1 mmol/L v. ≤ 8.3 mmol/L) did not influence either mortality or risk of hypoglycemia. Interpretation: Intensive insulin therapy significantly increased the risk of hypoglycemia and conferred no overall mortality benefit among critically ill patients. However, this therapy may be beneficial to patients admitted to a surgical ICU.

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1,034 citations

Journal Article•DOI•

Epidemiology of burns throughout the world. Part I: Distribution and risk factors

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Michael Peck¹•Institutions (1)

University of Arizona¹

01 Nov 2011-Burns

TL;DR: The epidemiology and risk factors of burns injuries worldwide are reviewed and it is shown that in high-income countries, burns occur disproportionately to racial and ethnic minorities such that socioeconomic status--more than cultural or educational factors--account for most of the increased burn susceptibility.

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760 citations

Journal Article•DOI•

Reversal of catabolism by beta-blockade after severe burns.

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David N. Herndon¹, David W. Hart², Steven E. Wolf², David L. Chinkes², Robert R. Wolfe² - Show less +1 more•Institutions (2)

Shriners Hospitals for Children - Galveston¹, University of Texas Medical Branch²

25 Oct 2001-The New England Journal of Medicine

TL;DR: In children with burns, treatment with propranolol during hospitalization attenuates hypermetabolism and reverses muscle-protein catabolism.

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Abstract: Background The catecholamine-mediated hypermetabolic response to severe burns causes increased energy expenditure and muscle-protein catabolism. We hypothesized that blockade of β-adrenergic stimulation with propranolol would decrease resting energy expenditure and muscle catabolism in patients with severe burns. Methods Twenty-five children with acute and severe burns (more than 40 percent of total body-surface area) were studied in a randomized trial. Thirteen received oral propranolol for at least two weeks, and 12 served as untreated controls. The dose of propranolol was adjusted to decrease the resting heart rate by 20 percent from each patient's base-line value. Resting energy expenditure and skeletal-muscle protein kinetics were measured before and after two weeks of beta-blockade (or no therapy, in controls). Body composition was measured serially throughout hospitalization. Results Patients in the control group and the propranolol group were similar with respect to age, weight, percentage of tota...

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569 citations