Nutritional Support and Neurotrauma: A Critical Review of Early Nutrition in Forty-Five Acute Head Injury Patients

Abstract

Forty-five acute head trauma patients were randomized into a neurotrauma nutritional study to compare the efficacy of two forms of standard nutritional supplementation; namely total parenteral nutrition (TPN) versus enteral nutrition (NG). Forty patients were male, 5 were female, with a median age of 28 years. The mean admitting Glasgow coma scale score was 5.8. Patients were given high calorie and nitrogen feedings for the 14 days of the study period in an attempt to achieve positive calorie and nitrogen balance. TPN patients had significantly higher mean daily nitrogen intakes (P less than 0.01) and mean daily nitrogen losses (P less than 0.001) than the NG fed patients; however, no significant differences were discovered with respect to maintenance of serum albumin levels, weight loss, the incidence of infection, nitrogen balance, and final outcome. The exaggerated nitrogen excretion experienced by patients fed large nitrogen loads illustrates a problem in achieving nitrogen equilibrium in acute head injured patients.

Nutritional Support After Spinal Cord Injury

“…3,6,7,12 They have been identified and studied in human patients who have sustained traumatic brain and spinal cord injuries. A number of publications have described the increased energy requirements and nitrogen losses of patients following acute head injury.…”

“…A number of publications have described the increased energy requirements and nitrogen losses of patients following acute head injury. 1,3,5,7,9,[12][13][14][15] Fewer studies have focused on hypermetabolism, catabolism, and nitrogen losses following acute SCI. 4,7,10,16,17 While there are metabolic similarities between isolated traumatic brain injury and severely isolated SCI, it appears there may be important biological differences between the 2 central nervous system (CNS) injury types that have bearing on supplemental nutritional therapy.…”

“…4,7,10,16,17 While there are metabolic similarities between isolated traumatic brain injury and severely isolated SCI, it appears there may be important biological differences between the 2 central nervous system (CNS) injury types that have bearing on supplemental nutritional therapy. [4][5][6][7][8]16,17 Severe head injury is associated with a resting energy expenditure (REE) of approximately 140% of predicted normal basal energy expenditure 3,5,7,[12][13][14][15] Indirect calorimetry is the most widely used reliable means to determine individual energy requirements in hospitalized patients after traumatic injury. 3,[5][6][7] It requires the use of a portable metabolic cart and employs a technique that measures respiratory gas exchange and the rate of oxygen utilization in a given patient.…”

“…Hypermetabolism, accelerated catabolism, and excessive nitrogen losses continue for at least 2 weeks after injury. 2,3,5,7,12,13 The exact duration of this response to injury is unknown, may vary among similar patients, and can be affected by other traumatic injuries, pancreatitis, infection, or sepsis. 3,[5][6][7]18 Nutritional support in this setting is designed to provide nitrogenrich, high-energy supplemental fuel to blunt excess catabolism and preserve energy stores, muscle mass, gastrointestinal integrity, and immune competence.…”

“…[4][5][6][7]16,17,[19][20][21][22][23] Agitated, combative head-injured patients, for example, can have REEs as high as 200% of expected basal energy expenditure levels. 3,5,7,12 Conversely, pharmacological paralysis of head-injured patients has been associated with reductions in resting energy expenditure by 20% to 30%. 3,5,7,12 Patients who have sustained isolated acute SCI often have increased metabolic expenditure compared to normative energy expenditure levels.…”