Neurosurgery notes/Trauma/Management of trauma/Non surgical/Nutrition

Nutrition

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Non surgical

General

  • TBI was associated with hypermetabolic state and excessive nitrogen wasting,
    • Mech likely from a centrally mediated mechanism
  • Studies from other critical illnesses have demonstrated that controlling this response with the use of insulin can lead to significant improvements in outcomes of critically ill patients
    • A similar approach in a population of adults with severe TBI demonstrated a worrisome pattern of metabolic responses within the brain interstitial fluid, implying that the practice of “tight glucose control” could have deleterious effects in patients with severe TBI.

Recommendation

  • Calculation for daily caloric intake
    • Basic weight-based equation (25–30 kcal/kg/d) be applied to determine energy requirements in critically ill patients
    • Protein should be 20% of calories
  • Monitor weight weekly
  • Early (within 24-48 hours) Enteral nutrition > Late
  • Enteral nutrition > Parental nutrition
    • Access through the gut serves as a passageway for immune-modulating substances and is effective in preventing stress ulcers
    • Be careful for EN in haemodynamically unstable pt:
      • Should be withheld in hemodynamically unstable patients
      • If a patient receiving vasopressor therapy is provided with EN, close attention should be paid to intolerance signs such as abdominal distention, hypoactive bowel sounds, decrease in stool passing, and metabolic acidosis, which are early signs of gut ischemia.
      • EN should be discontinued until stabilization of the symptoms and interventions.
  • Delay gastric emptying
    • Delayed gastric emptying may be assumed when there is feeding tube intolerance with large gastric residual volume.
    • Due to
      • Raised ICP
      • Stress
      • Ileus
        • More commonly when brain injury is accompanied by the spinal cord injury
    • Ways to reduce feeding tube intolerance
      • 45° head-of-bed elevation position to prevent aspiration pneumonia and to minimize gastroesophageal or laryngopharyngeal reflux of gastric contents
      • Concentrated enteral formulas (≥ 1.5 kcal/mL) may reduce the risk of reflux or intolerance while meeting caloric requirements in less volume
      • For EN, a continuous infusion is preferred rather than administration as a bolus.
        • Continuous has more positive effects on nitrogen balance and decreasing the hypercatabolic response in patients with TBI than intermittent EN and parenteral methods
  • Avoiding excessive hyperglycemia (> 10–11 mmol/L) and sustaining “permissive” glycemic control between 8 to 11 mmol/L are currently recommended
  • Carney 2017: full caloric replacement should be achieved by day five, and at the latest by day seven, postinjury
  • Wang 2013: Meta- analysis found that early feeding (defined in most studies as within 48 hours of admission) was associated with a significant reduction in mortality, poor outcomes, and infectious complications

Management of patients with TBI

Issues
Recommendations
Determination of the energy expenditure
- Increased energy demand after TBI may lead to hypermetabolism and hypercatabolism which are associated with increased morbidity and weight loss.
- Indirect calorimetry is the current “gold standard” for the determination of REE in patients with TBI, however, there are several practical difficulties. A published predictive equation or a basic weight-based equation (25–30 kcal/kg/d) is an alternative measure.
- Weekly monitoring for weight gain or loss is useful during inpatient rehabilitation.
Delayed gastric emptying and intolerance to EN
- Gastric access is the standard method for initiating EN in patients with TBI. However, delayed gastric emptying is one of the major complications that may be observed in up to 50% of patients with TBI.
- Proper positioning, continuous infusion, and motility promoting agents such as metoclopramide are recommended strategies for gastroparesis after TBI. Concentrated enteral formulas (≥ 1.5 kcal/mL) may reduce the intolerance.
Route and timing of access in patients who are unable to maintain volitional intake: EN versus PN
- Early EN (within 24–48 hours) is recommended in patients with TBI.
- Use of supplemental PN be considered after 7–10 days if unable to meet > 60% of energy and protein requirements by the enteral route alone.
- If EN is contraindicated in severely malnourished patients, PN should be implemented progressively within 3–7 days, rather than no nutrition.
Selecting immune-modulating enteral formulas
Immune-modulating formulation containing arginine or EPA/DHA supplementation in addition to standard enteral formula is suggested in patients with acute TBI . Although not yet suggested in CPGs, previous studies showed that intravenous BCAA (e.g., leucine) infusion decreased mortality and disability in patients with severe TBI.
Glycemic control
Sustaining ‘permissive’ glycemic control between 8 to 11 mmol/l are currently recommended in patients with TBI.
Protein support
Maintaining protein balance during both acute and post-acute TBI is important. It is recommended that protein supply should account for 15%–20% of total calories, and administration at least 2 g/kg body weight per day in patients with TBI.
  • REE, resting energy expenditure; TBI, traumatic brain injury; EN, enteral nutrition; PN, parenteral nutrition; EPA, eicosapentaenoic acid; DHA, docosahexaenoic acid; CPG, clinical practice guidelines; BCAA, branched-chain amino acids.