Micronutrient and electrolyte management in burns

Overview

Severe burn injury produces profound depletion of micronutrients through multiple mechanisms: exudative losses of trace elements and vitamins through burn wound fluid, increased metabolic demand driven by the hypermetabolic response, redistribution of trace elements to visceral organs, and impaired absorption ^[1][2]. The trace elements most affected are selenium, zinc, and copper, all of which play essential roles in antioxidant defense, immune function, and wound healing ^[1][3]. Micronutrient deficiency compounds the oxidative stress and immunosuppression inherent to severe burn injury and is associated with increased infectious complications, delayed wound healing, and prolonged hospitalization ^[4]. Proactive supplementation strategies are therefore a core component of burn nutritional care.

Trace element physiology in burns

Following burn injury, plasma concentrations of selenium and zinc decrease rapidly (within 6 hours) while copper levels rise due to hepatic acute-phase protein synthesis (ceruloplasmin) ^[5]. Agay et al. demonstrated in an animal model that copper and zinc are redistributed to the liver and selenium to the kidney following burn injury, with minimal changes in muscle and brain concentrations ^[5]. These redistributive changes, combined with ongoing exudative losses through burn wound fluid, create negative trace element balances that persist for weeks ^[3]. Berger and Shenkin described this as an inherent imbalance in endogenous antioxidant capacity that extends primary tissue injury and contributes to the systemic inflammatory response ^[3].

Supplementation evidence

A systematic review and meta-analysis by Kurmis et al. evaluated eight trials (398 participants) and found that parenteral supplementation of combined trace elements (selenium, copper, and zinc) was associated with a significant decrease in infectious episodes (weighted mean difference: -1.25 episodes; 95% CI: -1.70, -0.80; P < 0.00001) ^[1]. Combined parenteral trace element supplementation and combined oral and parenteral zinc supplementation showed potentially clinically significant reductions in length of stay ^[1]. Oral zinc supplementation showed possible beneficial effects on mortality, though definitive studies are needed ^[1].

Rehou et al. conducted a cohort study of 172 patients (mean 33% TBSA burned) and found that patients receiving intravenous antioxidant and trace element supplementation had significantly lower inflammatory markers at both early and late time points, decreased hypermetabolic response, shorter length of stay (adjusted RR 0.78; 95% CI 0.66-0.92), and improved bacterial clearance ^[4].

Burn size thresholds for supplementation

Kurjatko et al. investigated the relationship between burn size and trace element deficiency risk in 53 patients ^[6]. Receiver operating characteristic analysis identified a 22.1% body surface area burned (BSAB) cutoff for zinc deficiency risk (91.7% sensitivity, 92.6% specificity) and a 27.5% BSAB cutoff for copper deficiency (88.9% sensitivity, 81% specificity) ^[6]. No patient developed selenium deficiency regardless of burn size in their predominantly enteral supplementation cohort ^[6]. Patients with greater than 30% BSAB developed deficiencies in both zinc and copper within the first two weeks of hospitalization ^[6].

Practical supplementation

Berger and Shenkin provided practical guidelines for micronutrient supplementation in critically ill patients, emphasizing several key principles ^[7]: micronutrient supplementation should begin from the first day of nutritional support; testing blood levels of vitamins and trace elements in acutely ill patients is of limited value because acute-phase changes confound interpretation; patients with major burns develop acute deficits rapidly and immediate supplementation is essential; and high losses through excretion should be minimized by infusing micronutrients slowly over as long a period as possible ^[7].

Vitamins

Saeg et al. conducted a systematic review of nutritional interventions in wound care and found that burn wound outcomes improved in patients receiving vitamins A, B1, B6, B12, D, E and trace elements including zinc, calcium, copper, magnesium, and selenium ^[8]. Vitamin C supplementation has been studied as an adjunct during burn resuscitation for its antioxidant properties and potential to reduce fluid requirements, though evidence remains mixed. Vitamin D deficiency is nearly universal in burn patients and is addressed separately (see mineral-and-bone-metabolism-after-burns).

Electrolyte management

Electrolyte derangements are common in burn patients across all phases of care. Hypocalcemia occurs frequently due to disrupted vitamin D metabolism and parathyroid hormone suppression (see mineral-and-bone-metabolism-after-burns). Hypomagnesemia and hypophosphatemia occur secondary to increased urinary losses, intracellular shifts during refeeding, and exudative wound losses. Moreira et al. emphasized that calorie deficit, negative protein balance, and antioxidant micronutrient deficiency after thermal injury are all associated with poor clinical outcomes and require personalized nutritional therapy ^[9].

Controversies and Evidence Gaps

Optimal dosing regimens, routes of administration (enteral vs. parenteral vs. combined), and duration of trace element supplementation are not standardized across burn centers. Whether selenium supplementation is necessary in patients with adequate enteral intake remains unclear. The clinical significance of acute-phase changes in trace element levels versus true deficiency is difficult to distinguish. Burn-specific vitamin C dosing during resuscitation lacks multicenter randomized trial support. Refeeding syndrome risk in malnourished burn patients requires further study to define monitoring protocols. The interaction between trace element supplementation and antibiotic therapy (particularly zinc and fluoroquinolone absorption) needs clarification.

References

[1] Kurmis R et al. "Trace Element Supplementation Following Severe Burn Injury: A Systematic Review and Meta-Analysis." J Burn Care Res 2016;37:143-159. PMID: 26056754 [2] Zemrani B et al. "Recent insights into trace element deficiencies: causes, recognition and correction." Curr Opin Gastroenterol 2020;36:110-117. PMID: 31895229 [3] Berger MM et al. "Trace elements in trauma and burns." Curr Opin Clin Nutr Metab Care 1998;1:513-517. PMID: 10565403 [4] Rehou S et al. "Antioxidant and Trace Element Supplementation Reduce the Inflammatory Response in Critically Ill Burn Patients." J Burn Care Res 2018;39:1-9. PMID: 28877128 [5] Agay D et al. "Alterations of antioxidant trace elements (Zn, Se, Cu) and related metallo-enzymes in plasma and tissues following burn injury in rats." Burns 2005;31:366-371. PMID: 15774296 [6] Kurjatko A et al. "Trace Element Supplementation in Burn Patients: Exploring the Relationship Between Burn Size and Mineral Needs." J Burn Care Res 2025;46:411-418. PMID: 39269627 [7] Berger MM et al. "Vitamins and trace elements: practical aspects of supplementation." Nutrition 2006;22:952-955. PMID: 16928476 [8] Saeg F et al. "Evidence-Based Nutritional Interventions in Wound Care." Plast Reconstr Surg 2021;148:226-238. PMID: 34181622 [9] Moreira E et al. "Update on metabolism and nutrition therapy in critically ill burn patients." Med Intensiva 2017;42:306-316. PMID: 28951113