..

..
. .
... .
... .
.
.. .
.. ..
..
. .

...

Association of General Surgeons of Thailand

under the Royal Patronage of HM the King
2
10310
. 0-2716-6450 0-2716-6451
Royal Golden Jubilee Building, 2 Soi Soonvijai,
New Petchburi Road, Bangkok, 10310, Thailand.
Tel. (662) 716-6450 FAX (662) 716-6451
www.thaisurgeons.or.th

.. .
..
..
..
.
..
...
...
.
..
..

3/3 49 10110
. 0-2258-7954, 0-2662-4347
0-2258-7954
E-mail : bkkmed@gmail.com

 9 3 - 2556

Vol. 9 No. 3 September-December 2013

45

. .

46

49

Advanced wound dressings

2
(Clinical Results of Advanced Wound Dressings in Second-degree Pediatric Burns)
, ..

Original Article

54

Retrospective Study Comparing Outcome of Urgent Versus Elective Hemorrhoid

ectomy; Maharat Nakhon Ratchasima Hospital
Prinya Santichatngam, MD
Saowanee Kitudomrat, MD

59

Nutrition Therapy for Major Trauma and Major Burn Patients: Enteral Feeding
, ..

Journal of the Association of General Sugeons of Thailand under the Royal Patronage of HM the King
Vol. 8 No. 16 May-August 2012

3 2556
www.thaisurgeons.or.th

(. . )

45


9 3 - 2556

46

, , ,
Monitor

(Invasive)

(Risk Management)

Thomas Schlich
369:21 21 2013

,
,

1870
(Antisepsis)
19
Antisepsis
Management of Chance
Nikolay
Pigorov On Luck in Surgery
..1854

Pigorov

,
Economy of risk

Journal of the Association of General Sugeons of Thailand under the Royal Patronage of HM the King
Vol. 9 No. 3 September-December 2013

Pigorov

.. 1881
Richard von Volkmann
(Traditional Surgeon)

Volkmann
.Joseph Lister

15

Antisepsis

Johann von Mikulicz
Breslau

(Anesthesia) 1840

Theodor Kocher
1883 Strumectomies
Thyroid Goitre 100 250
1889 1,000
1895 update 1901,1906
1909 1,000
Kocher
14% 0.5%


1907 Kocher

Kocher
Kocher

1990 Lucian
Leape (JAMA 1994:272:1851-7)

47


9 3 - 2556

48

Journal of the Association of General Sugeons of Thailand under the Royal Patronage of HM the King
Vol. 9 No. 3 September-December 2013

Advanced wound dressings

2
(Clinical Results of Advanced Wound
Dressings in Second-degree Pediatric Burns)
, ..*
*

Abstract
Clinical Results of Advanced Wound Dressings in Second-degree Pediatric Burns
Anan Watcharhachittitam M.D.
Introduction: The purpose of second-degree burn wound treatment is the promotion of wound healing
mechanism. Many advanced wound dressings have been used in treatment of many wounds. In this study, will find out
the clinical results of advanced wound dressings in treatment of second-degree pediatric burn.
Methods: Retrospective study, reviewed pediatric (0-15 years) burn registry data from plastic and reconstructive surgery unit in Nakornping hospital, Chiangmai, Thailand from June 2008 through May 2013 for in-patients
with second-degree burns treated with Advanced wound dressings (n=30) , included Allevyn Ag Non-adhesive (Smith
& Nephew), Aquacel Ag (Convatec) and Askina Calgitrol Ag (B Braun). A comparison group was composed of
patients treated with silver sulfadiazine cream (Conventional Technique) (n=31) and matched for age, sex, type and
%TBSA burned.
Results: Advanced wound dressings-treated pediatric patients had a shorter hospital length of stay from 8 to
4 days (P=0.002), had a shorter time to re-epithelialization from 16.3 3.3 days to 11.1 1.4 days (P<0.001), were
significantly lower in dressings change from 16.3 3.3 times to 2.7 0.5 times (P<0.001). Nurses and parents
satisfaction were better (P<0.001), and hospital costs were not significant (P=0.498).
Key words: Second-degree burn wound, Advanced wound dressings, Conventional technique

2
Advanced wound dressings 2
(Conventional technique)
: Retrospective study 15
.. 2551 .. 2556 61
31 (Advanced wound dressings) 30
Allevyn Ag Non-adhesive (Smith & Nephew), Aquacel Ag (Convatec) Askina Calgitrol Ag (B Braun)
: 61

2 Advanced wound dressings (Hospital
length of stay) 8 4 (P=0.002) (Time to Re-epithelialization)
16.3 3.3 11.1 1.4 (P<0.001) 16.3 3.3 2.7
0.5 (P<0.001) (P<0.001)
( Hospital cost ) (P=0.498)
: 2, Advanced wound dressings,

49


9 3 - 2556

50

2




1,2
(Conventional technique)
Silver sulfadiazine cream
(Advanced wound dressings)


3-12
Advanced
wound dressings
2
(Conventional technique)

dressings)
1. Allevyn Ag Non-adhesive (Smith &
Nephew) Hydrocellular foam dressing with
silver sulfadiazine
2. Aquacel Ag (Convatec) Hydrofiber
wound dressing with ionic silver
3. Askina Calgitrol Ag (B Braun) Silver alginate dressing


(% burn)

Retrospective
study

15

.. 2551 ..
2556 5 67

61
2 ( 6

3
) 2
(Conventional technique) 31
(Advanced wound
dressings) 30
(Advanced wound

2
61
1
2
(Advanced wound dressings)
30 23 (73.8%) 7
(26.2%)
(Conventional technique) 31
22 (76.7%) 9 (23.3%)
(P=0.772)
Advanced
wound dressings 6 15
( 24 ) (Conventional technique) 9 15
( 48 ) (P=
0.265)

Advanced wound dressings

Journal of the Association of General Sugeons of Thailand under the Royal Patronage of HM the King
Vol. 9 No. 3 September-December 2013

(Conventional technique)
(P= 0.235)
(Scald burn)
25 (83.3%) 21 (67.7%)
(Flame
burn) 5 (16.7%) 10 (32.3%)

(% Burn)
Advanced wound dressings 2-20% (Conventional technique) 1-49% 8%

(P= 0.366)

3
2 Advanced wound dressings Conventional technique
( Silver sulfadiazine cream)
(Hospital length of stay)
8 4 (P=0.002)

:
: (%)

(): (%)
6-24
25-72
73-180
Median (iqr*)

Advanced dressing

Conventional technique

P-Value

30

31

23(73.8)
7(26.2)

22(76.7)
9(23.3)

0.772

18(60.0)
3(10.0)
9(30.0)
24(72)

13(41.9)
6(19.4)
12(38.7)
48(120)

0.265

Advanced dressing

Conventional technique

P-Value

25(83.3)
5(16.7)
8(5)

21(67.7)
10(32.3)
8(6)

0.235
0.366

26(86.7)
20(66.7)
20(66.7)
19(66.3)
8(26.7)

27(87.1)
21(67.7)
18(54.8)
18(54.8)
11(35.5)

>0.999
>0.999
0.434
0.795
0.582

*iqr; inter-quartile range

Burn types: (%)

Scald
Flame
%Burn: Median (iqr)
: (%)

51


9 3 - 2556
3

1.
2.
3.
4.
5.

52

Hospital length of stay Day; Median (iqr)

Time to Re-epithelialization Day; Mean+/-SD
Number of dressing change Mean+/-SD
Hospital cost Baht; Median(iqr)
Satisfaction score(1-5) Median(iqr)
Nurse
Parents

Advanced dressing

Conventional technique

P-Value

4(4)
11.11.4
2.70.5
12,660(19,545)

8(7)
16.33.3
16.33.3
12,251(17,815)

0.002
<0.001
<0.001
0.498

5(0)
4.5(1)

2(1)
2(1)

<0.001
<0.001

(Time to Re-epithelialization)
16.3 3.3 11.1 1.4 (P<0.001)
16.3
3.3 2.7 0.5 (P<0.001)
(Hospital
cost) 2 (P=0.498)
Advanced wound dressings
12,660 conventional
technique 12,251
(Satisfaction score)
Advanced wound dressings

(Conventional technique)
(P<0.001)

Advanced wound dressings

3-12
Advanced wound dressings

3
1. Allevyn Ag Non-adhesive (Smith &
Nephew) Hydrocellular foam dressing with
silver sulfadiazine polyurethane foam
exudate

()

2. Aquacel Ag (Convatec) Hydrofiber
wound dressing with ionic silver
hydrofiber

3. Askina Calgitrol Ag (B Braun) Silver alginate dressing foam exudate

1.

Allevyn Ag
Aquacel Ag
Askina Calgitrol Ag
2.

Journal of the Association of General Sugeons of Thailand under the Royal Patronage of HM the King
Vol. 9 No. 3 September-December 2013

Aquacel Ag

3.
Allevyn Ag Aquacel Ag
3-4
Askina Calgitrol Ag
3-6
Advanced wound
dressings
2

4.

5.

6.

7.

Advanced wound dressings

2
1.
2.
3.
4.
5.

8.

9.

10.

1. Klein MB. Thermal, chemical and electrical injuries. In

Grabb & Smiths Plastic Surgery. 6th ed. Thorne CH, editor-in-chief. Wolters Kluwer/Lippincott Williams & Wilkins;
132-49.
2. Laitakari E, Pyorala S, Koljonen V. Burn injuries requiring
hospitalization for infants younger than 1 year. J Burn
Care Res 2012;33:436-41.
3. Paddock HN, Fabia R, Giles S, Hayes J, Lowell W, Adams

11.

12.

D, et al. A silver-impregnated antimicrobial dressing reduces hospital costs for pediatric burn patients. J Pediatr
Surg 2007;42:211-3.
Saba SC, Tsai R, Glat P. Clinical evaluation comparing
the efficacy of Aquacel Ag hydrofiber dressing versus petrolatum gauze with antibiotic ointment in partial thickness burns in a pediatric burn center. J Burn Care Res
2009;30:380-5.
Barnea Y, Weiss J, Gur E. A review of the applications of
the hydrofiber dressing with silver (Aquacel Ag) in wound
care. Thera Clin Risk 2010;6:21-7.
Caruso DM, Foster KN, Blome-Eberwein SA, Twomey JA,
Herndon DN, Luterman A, et al. Randomized clinical study
of hydrofiber dressing with silver or silver sulfadiazine in
the management of partial thickness burns. J Burn Care
Res 2006;27:298-309.
Paddock HN, Fabia R, Giles S, Hayes J, Lowell W, Besner
GE. A silver impregnated antimicrobial dressing reduces
hospital length of stay for pediatric patients with burns. J
Burn Care Res 2007;28:409-11.
Glat PM, Kubat WD, Hsu JF, Copty T, Burkey BA, Davis
W, et al. Randomized clinical study of SilvaSorb gel in
comparison to Silvadene silver sulfadiazine cream in the
management of partial thickness burns. J Burn Care Res
2009;30:262-7.
Aziz Z, Abu SF, Chong NJ. A systematic review of silvercontaining dressings and topical silver agents (used with
dressings) for burn wounds. Burns 2012;38:307-18.
Barret JP, Dziewulski P, Ramzy PI, Wolf SE, Desai MH,
Herndon DN. Biobrane versus 1% silver sulfadiazine in
second-degree pediatric burns. Plast Reconstr Surg 2000;
105:62-5.
Ou LF, Lee SY, Chen YC, Yang RS, Tang YW. Use of
Biobrane in pediatric scald burns - experience in 106 children. Burns 1998;24:49-53.
Lesher AP, Curry RH, Evans J, Smith VA, Fitzgerald MT,
Cina RA, et al. Effectiveness of Biobrane for treatment of
partial thickness burns in children. J Pediatr Surg 2011;
46:1759-63.

53


9 3 - 2556

Original Article

Retrospective Study Comparing Outcome

of Urgent Versus Elective Hemorrhoidectomy;
Maharat Nakhon Ratchasima Hospital
Prinya Santichatngam, MD*
Saowanee Kitudomrat, MD*
*Department of Surgery, Maharat Nakhon Ratchasima Hospital

54

Abstract
Introduction: Hemorrhoid is a very common benign surgical pathology. Urgent hemorrhoidectomy was performed to relieve pain, but may increase risks of complications. Objective: To compare the
operative outcomes(postoperative complications, operative time, and recurrence rate) between patients undergoing urgent and elective hemorrhoidectomy. Research design: Retrospective, comparative study. Materials
and methods: All records of the patients who underwent urgent and elective hemorrhoidectomy in Maharat
Nakhon Ratchasima Hospital between June 2008 and May 2009 were reviewed. Operative outcome(complication:
bleeding, urinary retention, post-operative thrombosis, and wound dehiscence), operative time, and recurrence
rate were analyzed. Statistical analysis: Unpaired t-test (two-tails), Chi-square with Yates correction Results:
There were 94 patients in the urgent hemorrhoidectomy group (group 1) and 25 patients in elective
hemorrhoidectomy group (group 2). No differences were found between two groups in gender, age, number
of hemorrhoidectomy and pre-operative hematocrit. Chief complaint of all patients in group 1 were anal pain,
on the other hand, of most patients in group 2 were mainly prolapsed anal mass. Difference from group 2,
group 1 had more underlying, alcoholism, smoking patients. In mean operative time, group 1 had longer time
than group 2 about 8.2 minutes. It was statistical significance (P<0.05), but there was no clinically significant
difference. Conversely, 24 hours post-operative complication (urinary retention) patients in group 1 was more
than ones in group 2, but there was no statistical significance (P>0.05). Conclusion: There was no statistical
significant in postoperative outcome in term of complications (urinary retention, recurrence rate) between
urgent and elective hemorrhoidectomy.
Key words: urgent versus elective hemorrhoidectomy, outcome

, ..*, , ..*
*


Retrospective, comparative study


1 2551 31 2552

Journal of the Association of General Sugeons of Thailand under the Royal Patronage of HM the King
Vol. 9 No. 3 September-December 2013

, , 2

, , mean, SD, unpaired t-test (two-tails), Chi-square with

Yates correction P<0.05

( 1) 94 ( 2) 25
1
2
1 2 8.2
(P<0.05) 24 ()
(%) 2 (P>0.05)
24 ()
2
(P>0.05)
: ,

Background

emorrhoid, which is one of the most

common anorectal disorders, is classified
to external and internal hemorrhoids by the location of pathology related to the dentate line.
Internal hemorrhoid is graded by the extent of
prolapse from first to fourth degree. The first
and the second degrees is conservatively treated
with diet modification and medications to keep
stools soft, from and regular. For the patient with
the third degree of hemorrhoid, the surgical management, also known as hemorrhoidectomy, can
be considered. The fourth degree and thrombosed external hemorrhoids usually require urgent actions for relieving pain. After 48-72 hours
of symptoms, thrombosis will lyse spontaneously
and clinically improved. Compare with the elective surgery, the urgent hemorrhoidectomy is
more complicated and may result in urinary retention, postoperative pain, bleeding and infec-

55

tion.
The objective of this study was to compare
outcomes (operation time, post-operative complication and recurrence rate at post-operation
2 weeks) of urgent and elective hemorrhoidectomy in retrospective study.

Patients and Methods

Medical records of patients with hemorrhoids who underwent urgent and elective hemorrhoidectomy in Maharat Nakhon Ratchasima
Hospital were collected from June 1, 2008 to
May 31, 2009. There were 94 patients in urgent
group and 25 patients in elective group. Gender, age, symptoms and underlying diseases
were collected. The outcomes(operation time,
post-operative, complication and recurrence rate
at post-operation 2 weeks) were compared. This
paper was approved by ethical committee board
of Maharat Nakhon Ratchasima Hospital.


9 3 - 2556

Results

Statistical analysis
Number, Percent, Mean, SD, Unpaired t-test
(two-tails), Chi-square with Yates correction,
Odds ratio (OR), 95% confidence interval (CI) of
OR) were used for analysis. P<0.05 were considered statistical significance.

Patients demographic data was shown in

Table 1. There were 94 patients in the urgent
hemorrhoidectomy group (group 1) and 25 patients in elective hemorrhoidectomy group (group
2). No difference was found between two groups

Table 1 Demographic data

56

Patient
Numbers of patient
Sex (female : male)
Age (yrs) (mean (SD))
Symptom (cases)
Mass
Pain
Bleeding
Underlying Disease
DM
HT
CRF
TB
Old CVA
Thalassemia
Thyroid disease
History previous anal surgery
Alcoholism
Smoking
Occupation
No
Private business
Employee
Farmer
Official
Monk
Housewife
Preoperative Hematocrit (%) (mean(SD))
Diagnosis
Internal hemorrhoid
External hemorrhoid
Combined hemorrhoid
Numbers of hemorrhoidectomy (mean(SD))
Surgeon (staff)
Choices of anesthesia
Local
Regional (spinal block)
General

Urgent hemorrhoidectomy
94
34:60
49.1(14.29)

Elective hemorrhoidectomy
25
17:8
43.7(12.52)

75
94
23
18(19.1%)
4(4.3%)
4(4.3%)
14(14.9%)
1(1.1%)
0
2(2.1%)
1(1.1%)
4
35
33

20
1
9
4(16%)
0
2(8%)
0
0
2(8%)
0
0
2
2
3

9
4
28
24
11
5
13
34.9(7.20)

2
5
5
3
6
0
4
36.5(3.71)

0
54
40
1.8(0.82)
9

11
6
8
1.5(0.59)
17

14
78
2

12
11
2

Journal of the Association of General Sugeons of Thailand under the Royal Patronage of HM the King
Vol. 9 No. 3 September-December 2013
Table 2 Mean operation time of urgent and elective hemorrhoidectomy

Operative time (minutes) (mean(SD))

Urgent hemorrhoidectomy
22.8 (5.14)

Elective hemorrhoidectomy
14.6 (7.85)

P
<0.001*

*Statistical significance (P< 0.05)

Table 3 Complications of urgent and elective hemorrhoidectomy

Patient
(cases (%))
Post-operative complication
(urinary retention)
Recurrence rate at post-operation
2 weeks

Urgent
hemorrhoidectomy
14 (14.9)

Elective
hemorrhoidectomy
2 (8)

0.57

OR
(95% CI of OR)
2.01 (0.39;13.85)

5 (5.3)

1 (4)

1.35 (1.35;31.97)

in gender, age, numbers of hemorrhoidectomy

and preoperative hematocrit. Main complaints
of all patients in group 1 were anal pain. On the
other hand, of patients in group 2 were mainly
prolapsed anal mass. Different from group 2,
group 1 had more underlying, alcoholism,
smoking patients. Group 1 had longer mean
operative time than group 2 about 8.2 minutes
(Table 2). It was statistical significance (P<0.05),
but not clinically significance. On the contrary,
24 hours post-operative complication (urinary retention) patients in group 1 were more than in
group 2, but it was no statistical significance
(Table 3). There were 14 of 16 patients with
post-operative complication under the regional
anesthesia, another with the local anesthesia
and the other with the general anesthesia.

Discussion
Patients with prolapsed thrombosed hemorrhoids usually suffer from pain. The management of this case is still controversial and the
optimal treatment is conservative or surgical
management. The best anesthetic method is

regional or local anesthesia. Greenspon, et al1

reported that conservative group needed 24 days
for symptoms resolution but only 4 days in surgical group and the recurrence rate was 25.4%
compared to 6.3% in surgical group. In spite of
the high complication rate in surgical treatment,
several studies2-6 have shown that hemorrhoidectomy is safe and effective for prolapsed thrombosed hemorrhoids and shortening those suffering experiences. Jogen, et al7 had retrospectively studied 340 patients with excision of
thrombosed external hemorrhoids with local
anesthesia. 6.5% of patients developed a recurrent thrombosed external hemorrhoid after 2
months of initial excision. Postoperative complications included 0.3% postoperative bleeding
controlled under local anesthesia and 2.1% developed a fistula or an abscess. Pattana-arun J,
et al8 prospectively, non-randomized studied 46
patients with prolapsed thrombosed internal
hemorrhoids who underwent urgent hemorrhoidectomy and 54 patients who underwent elective hemorrhoidectomy. Two patients in the elective group encountered postoperative bleeding

57


9 3 - 2556

2 weeks after an operation, 10.8% of the urgent

group and 11.7% of the elective group were found
to be wound dehiscence. There was no difference in postoperative bleeding and wound dehiscence between the urgent and the elective
hemorrhoidectomy. There was no statistical significance in postoperative outcome in term of
complications (urinary retention, recurrence rate)
between urgent and elective hemorrhoidectomy
(P<0.05).
The limitations of this study were not classified technique of hemorrhoidectomy. The operation was performed by varied surgeons (surgical residents, staffs). The severity of hemorrhoids in the elective group was different from
the urgent group.

58

Conclusion
There was no statistical significance in postoperative outcome in term of complications (urinary retention, recurrence rate) between urgent
and elective hemorrhoidectomy (P<0.05).

References
1. Greenspon J, William SB, Young HA, Orkin BA. Thrombosed external hemorrhoids: outcome after conservative
or surgical management. Dis Colon Rectum 2004;47:14938.
2. Barrios G, Khubchandani M. Urgent hemorrhoidectomy
for hemorrhoidal thrombosis. Dis Colon Rectum 1979;22:
159-61.
3. Rosen L, Sipe P, Stasik JJ, Riether RD, Trimpi HD. Outcome of delayed hemorrhage following surgical hemorrhoidectomy. Dis Colon Rectum 1993;36:743-6.
4. Ceulemans R, Creve U, Van Hee R, Martens C, Wuyts FL.
Benefit of emergency haemorrhoidectomy: a comparison
with results after elective operations. Eur J Surg 2000;
166:808-13.
5. Mazier WP. Emergency hemorrhoidectomy-a worthwhile
procedure. Dis Colon Rectum 1973;16:200-5.
6. Wang CH. Urgent hemorrhoidectomy for hemorrhoidal
crisis. Dis Colon Rectum 1982;25:122-4
7. Jongen J, Bach S, Stubinger SH, Bock JU. Excision of
thrombosed external hemorrhoid under local anesthesia:
a retrospective evaluation of 340 patients. Dis Colon Rectum 2003;46:1226-31.
8. Pattana-arun J, Weerachawit W, Tantiphlachiva K,
Sahakijrungruang S, Rojanasakul A. comparison of postoperative complications between urgent and elective closed
hemorrhoidectomy: A prospective study. Thai J Surg 2006;
27:26-9.

Journal of the Association of General Sugeons of Thailand under the Royal Patronage of HM the King
Vol. 9 No. 3 September-December 2013

Nutrition Therapy for Major Trauma and

Major Burn Patients: Enteral Feeding
, ..*
*, , ,

(Major
trauma) (Major burn)
(Holistic approach)

Villet S. 1

10,520
- 12,600 kcal (infectious complication),
(overall complication) ICU

(Nutrition therapy)

Initiate Enteral Feeding

Major trauma
(vital signs)

(nutritional status)

(evaluation of weight loss),
, ,
albumin prealbumin
feedings

2-6
bowel sound

Enteral
feeding (EN) Parenteral
nutrition (PN)
EN pneumonia, central line
infection Major
Trauma

PN 7-9 EN
24-48 .
10
major burns
major
burn basal metabolic rate
200%11-13
major burn
The European So-

59


9 3 - 2556

ciety for Clinical Nutrition and Metabolism

(ESPEN) (2013)14 nutritional therapy major burn
6-12 .
stress hormone hypermetabolic
response
EN
(goal of calories) 4872 . feeding
(hemodynamic compromise) significant hemodynamic support catecholamine
IV fluid blood
product resuscitation maintain
hemodynamic EN
hemodynamic stable

60

Dosing of Enteral Feeding

EN
goal of calories EN
energy requirements
energy requirements predictive equations indirect calorimetry
predictive equations
(accuracy) indirect calorimetry
2
(outcome) ICU,

indirect calorimetry
predictive equations
energy requirements4
Energy requirements
major trauma 3
goal of calories
energy requirements

3
(acute or initial phase)

(Systemic Inflammatory Response Syndrome or SIRS) exogenous energy supply 20-25 kcal/kg BW/day
outcome 3,11
SIRS
recovery (anabolic flow) phase
calories 20-35
kcal/kg BW/day
3
major burn
calories requirement 20-30 kcal/kg/
day
underfeeding major burn
Harris & Benedict equation overfeeding
ESPEN indirect calorimetry
gold standard calories
major burn indirect calorimetry ESPEN Toronto equation
Schofield equation

indirect calorimetry
( 1)
EN feeding 50-60 goal calories

EN 11
enteral feeding goal of calories
7-10 supplemental PN
goal of calories2 malnutrition supplemental PN
enteral feeding goal of
calories 72 .3

Journal of the Association of General Sugeons of Thailand under the Royal Patronage of HM the King
Vol. 9 No. 3 September-December 2013
1 Toronto Schofield equation major burn
Age category

Equation

Adults

Toronto

Girls 3-10 yrs

Boys 3-10 yrs
Girls 10-18 yrs
Boys 10-18 yrs

Schofield
Schofield
Schofield
Schofield

Requirement (kcal/day)
- 4343 + (10.5 x % TBSA) + (0.23 x caloric intake) + (0.84 x REE by
Harris-Benedict << crude >>) + (114 x t) - (4.5 x days after injury)
(16.97 x weight in kg) + (1,618 x height in cm) + 371.2
(19.6 x weight in kg) + (1,033 x height in cm) + 414.9
(8.365 x weight in kg) + (4.65 x height in cm) + 200
(16.25 x weight in kg) + (1,372 x height in cm) + 515.5

(High protein formula)3

1.2-2.0 g/
kg actual body weight per day
major burn2
major burn protein
1.5 -2 gm/kg/day
protein 2.2 gm/kg/day benefit 14
Carbohydrates major burn carbohydrates 7 gm/kg/
day 55-60%
major burn
6-8 mmol/
l (100-150 mg/dl)
major burn lipid


lipid (35%
15%) length of stay risk
infection lipid
35% omega-3
fatty acids

Monitoring Tolerance and Adequacy of Enteral Nutrition

EN
EN

(tolerance)
, ,
,
(abdominal radiographs)2 EN
gastric residual volumes
bowel feeding (Naso-duodenal tube
or Naso-jejunal tube) EN
(NPO)

(Ileus)
2

high gastric residuals

metoclopramide erythromycin intolerance
(intravenous)

enteral feeding

(enteral
feeding protocols)

(aspiration)
enteral feeding

- 30o-45o ICU patients endotracheal tube

61


9 3 - 2556

- gastric content EN
continuous infusion
- promote GI motility
prokinetic drugs (metoclopramide erythromycin)
-
post-pyloric tube feeding
- chlorhexidine mouth wash 2
colonize
Ventilator Associated Pneumonia (VAP)2

Selection of Appropriate Enteral Formulation

62

Glutamine
95 (intracellular) 12 Glutamine


Glutamine

Glutamine Glutamine
conditional essential amino acid
Glutamine
heat shock
protein-70 (HSP-70)
Arginine12 (essential
amino acid)

T-lymphocyte

white
blood cell intestinal mucosa cell
Arginine
Argenine
Nitric oxide (NO) NO vasodilatation sepsis
septic shock
-3 fatty acids

metabolism
eicosanoids

enteral nutrition
Immune-modulating enteral
formulations 2-4 Arginine,
Glutamine, Nucleic acid, -3 fatty acids
Antioxidants
,


enteral nutrition
1. Major elective (upper GI) surgery
2. Major Trauma Multiple trauma
3. Major Burns
4. Head and neck cancer
5. Critically ill patients
, Acute Lung Injury (ALI),
Acute Respiratory Distress Syndrome (ARDS)
6. mild sepsis APACHE II
score 15

Immune-modulating enteral
formulations
ARDS ALI
anti-inflammatory

Journal of the Association of General Sugeons of Thailand under the Royal Patronage of HM the King
Vol. 9 No. 3 September-December 2013

lipid profile -3 fish oils, borage oil

antioxidants
Arginine
Major burn Major trauma
Arginine
moderated severe
sepsis
Arginine
2
Glutamine Burn,
Trauma mixed ICU
Immune-modulating enteral
formulations
enteral feeding

50-60 goal of calories
700 calories
2,3

Micronutrient Requirements
major burn metabolic
change energy requirement
protein requirement micronutrient
micronutrient
metabolism
hypermetabolic response major burn
micronutrient inflammatory process wound healing micronutrient major burn vitamin B1, vitamin C, vitamin D, vitamin E, Copper (Cu), selenium (Se) zinc (Zn)

Non-Nutritional Management of Hypermetabolism

nutrition support

major burn
hypermetabolic response
major
28-30oC, early excision
coverage of deep burn wounds
protein synthesis nonselective beta-blockers (0.1 mg/kg/12 h
) oxandrolone (10 mg/12 h)

Major Trauma Major Burn

enteral feeding

Immune-modulating enteral formulations

References
1. Villet S, Chiolero RL, Bollman MD, Revelly JP, Cayeux RN
MC, Delarue J, et al. Negative impact of hypocaloric feeding and energy balance on clinical outcome in ICU patients. Clin Nutr 2005;24:502-9.
2. McClave SA, Martindale RG, Vanek VW, McCarthy M,
Robert P, Taylor B, et al. Guidelines for the Provision and
Assessment of Nutrition Support Therapy in the Adult
Critically III Patient: Society of Critical Care Medicine
(SCCM) and American Society for Parenteral and Enteral
Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr 2009;
33:277-316.
3. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet
P, Kazandjiev G, et al. ESPEN Guidelines on Enteral Nutrition: Intensive care. Clin Nutr 2006;25:210-23.
4. Canadian Clinical Practice Guidelines for Nutrition in the
Mechanically ventilated patients. 2012: Draft version
5. Raguso CA, Dupertuis YM, Pichard C. The role of visceral
proteins in the nutritional assessment of intensive care

63


9 3 - 2556

6.
7.

8.

9.

64

unit patients. Curr Opin Clin Nutr Metab Care 2003;6:21116.

Martindale RG, Maerz LL. Management of perioperative
nutrition support. Curr Opin Crit Care 2006;12:290-94.
Kudsk KA, Croce MA, Fabian TC, Minard G, Tolley EA,
Poret HA, et al. Enteral versus parenteral feeding: effects
on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg 1992;215:503-13.
Simpson F, Doig GS. Parenteral vs. enteral nutrition in the
critically ill patient: a meta-analysis of trials using the
intention to treat principle. Intens Care Med 2005;31:1223.
Peter JV, Moran JL, Phillips-Hughes J. A metaanalysis of
treatment outcomes of early enteral versus early parenteral
nutrition in hospitalized patients. Crit Care Med 2005;
33:213-20.

10. Marik PE, Zaloga GP. Early enteral nutrition in acutely ill
patients: a systematic review. Crit Care Med 2001;29:226470.
11. Krishnan JA, Parce PB, Martinez A, Diette GB, Brower
RG. Caloric intake in medical ICU patients: consistency of
care with guidelines and relationship to clinical outcomes.
Chest 2003;124:297-305.
12. Stipanuk MH, Caudill MA. Biochemical, physiological, and
molecular aspects of human nutrition. America: ELSEVIER.
3rd ed. 2013. p. 303-6.
13. Hart DW, Wolf SE, Mlcak R, Chinkes DL, Ramzy PI, Obeng
MK, et al. Persistence of muscle catabolism after severe
burn. Surgery 2000;128:312-9.
14. Rousseau A-F, Losser M-R, Ichai C, Berger MM. ESPEN
endorsed recommendations: Nutritional therapy in major
burns. Clin Nutr 2013;32:497-502.