American Burn Association Presidential Address 2006 on Nutrition: yesterday, today, and tomorrow.

Traditionally, the most hypermetabolic of all surgical diseases, appropriate nutrition has formed the basis of modern burn care. Today, I would like to review some of the highlights of that history, of where we in burn care have already been in delivering nutritional support for our patients and to promote continued research for the future. I submit that much of the improvement in burn mortality during the last quarter century (Figure 1) has come in conjunction with improvements in nutrition. During my nearly 30-year involvement in burn care, I have had the opportunity to see dramatic changes in nutritional management, many the result of this Association’s leaders. In the 1970s, it was well known that acutely injured patients could not use nutritional substrates for the first several days to a week after injury. There was, therefore, no need to feed them. Full nutrition was achieved when the team got around to it, often 7 to 10 days after the burn. Consequently, malnutrition was endemic, and burn patients often had the classical appearance of skin, bones, and a hank of hair. Although incremental changes have been made in topical and wound care, a review of surgical textbooks from the early 1980s show, by today’s standards, a striking lack of urgency in achieving adequate nutritional replacement. This was a time when Sir David Cuthbertson’s concept of metabolic ebb, or shock phase and the later flow phase divided into catabolic and anabolic portions, was an important part of our culture. The fact that posttraumatic ileus lasted a relatively long time, was a tenet that I think many trauma/ critical care people still believe. I hope to show you that the American Burn Association (ABA) and its members have played an important role in defining this change. Looking back, it seems as though the burn team has always been interested in nutrition. In 1956, 13 years before this organization’s formation, our first ABA president, Dr. Curtis P. Artz, recognized the special needs of the burn patient. It’s amazing how concepts change! Nutrition then was discussed as “achievable without forced feeding through an intragastric tube.” Today, we take that for granted. Some of his patients approached 5000 calories per day. That’s pretty good without a tube. This early formula was based on weight alone, with suggested intakes of 60 to 90 kcal and 2 to 3 g of protein per kilogram body weight. This was an era before small, soft tubes and commercial tube feedings. Those feedings were often the blenderized contents of a regular hospital tray thrown into a blender along with extra milk and, voila, tube feedings. Tubes clogged a lot in those days, especially if they had coleslaw on the tray. It was not as easy as today, where the exact contents are listed on the side of the can and the bulk sterile feeding comes with all of the needed vitamins and minerals. Those of us growing up in burn care in the late 1970s and early 1980s were raised on the Curreri Formula as a simple prediction of metabolic needs. P. William Curreri, later to become the 16th ABA President, was at the University of Texas Southwestern and Parkland then, along with Janet Marvin and Doctor Charles Baxter. One wonders how well Charlie accepted this when he burned himself and was under those junior authors’ tender, loving care. Their 1974 article in the Journal of the American Dietetic Association set the scene for what was to become the wellknown Curreri Formula. This suggested that daily From the Department of Surgery, University of Texas Southwestern Medical Center, Director, Burn Center, Parkland Health and Hospital Systems, Dallas, Texas. Presented at the 38 Annual Meeting of the American Burn Association, April 4–7, 2006, Las Vegas, Nevada. Address correspondence to Gary F. Purdue, MD, UT Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, Texas 75390-9158. Copyright © 2007 by the American Burn Association. 1559-047X/2007