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Nutritional Management of Traumatic Brain Injury

Nutritional Management of Traumatic Brain Injury. Melissa Wolynec Aramark Dietetic Intern February 13, 2012. The Patient. 24 year old male Admitted to ICU status post assault Intoxicated upon admission Intubated for airway protection and combativeness NG tube in place

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Nutritional Management of Traumatic Brain Injury

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  1. Nutritional Management of Traumatic Brain Injury Melissa Wolynec Aramark Dietetic Intern February 13, 2012

  2. The Patient 24 year old male Admitted to ICU status post assault Intoxicated upon admission Intubated for airway protection and combativeness NG tube in place Propofol drip for sedation

  3. The Patient Medically • Bilateral frontal contusions • Subarachnoid hemorrhage • Left temporal contusions • Swelling of brain • Monitored with daily CT scans

  4. Patient History • No previous medical history • Alcohol user • No drug or tobacco use • Appeared well nourished, stable weight • Appetite prior to admission unknown • No home medications

  5. Patient Weight • Admission Weight: 71.1 kg • BMI: 20.6 • 86% IBW

  6. Patient Nutrient Needs • Penn State Critical Non-Obese Formula • Stress Factors 1.2 – 1.4 • 2,381 to 2,778 kcal • 104 to 139 gm protein (1.5 to 2.0 gm/kg) • 2,079 to 2,772 mL fluid • Fed via NG tube using Glucerna 1.5

  7. The Injury – Traumatic Brain Injury (TBI) • Sudden trauma causing damage to brain • Head violently hits object • Bump, blow, jolt, fall • Object pierces through skill into brain • Bullet • May experience loss of consciousness or coma

  8. The Injury, Contd. • Mild TBI • Temporary dysfunction of brain cells • Serious TBI • Bruising, torn tissues, bleeding, physical damages to brain

  9. Symptoms of Severe TBI

  10. Complications

  11. Primary vs. Secondary Damage • Primary Damage • Intracranial hypertension • Increased cerebrospinal fluid • Secondary Damage • Brain swelling • Damage to brain cells

  12. About TBI • Ebb, or Initial Phase • Peaks at 48 to 72 hours • Subsides after 3 to 4 days • Decreased metabolism, temperature, cardiac output, energy expenditure • Flow, or Secondary Phase • Increased metabolism and catabolism • Last few days to few weeks

  13. Metabolic Alterations • Hormonal changes • Release of cortisol, epinephrine and norepinephrine • Changes in cellular metabolism • Increased energy expenditure, oxygen consumption • Cerebral and Systemic Inflammatory Response • Swelling

  14. Metabolic Alterations Contd. • Increased • Basal Metabolism • Oxygen Consumption • Glycogenolysis • Hyperglycemia • Results in muscle wasting

  15. Evidenced Based Nutrition – Early Nutrition • Database, 24 Level I and II trauma centers • Arrival 24 hours after injury • Glasgow Coma Score (GSC) < 9 • Exclusions: • Subarachnoid hemorrhage secondary to aneurysm or stroke • GCS 3-4 • Fixed, dilated pupils Hartl R, Gerber L, Ni Q, Ghajar J. Effect of Early Nutrition on Deaths Due to Severe Traumatic Brain Injury. Journal of Neurosurgery. 2008;109:50-56.

  16. Early Nutrition, Contd. • Energy requirements estimated at 25 kcal/kg/day • Mortality: death within 2 weeks after TBI • Initial: 1,818 patients, Final:1,261 patients • 61% began feeding Days 1-3 • 5% never fed over 7 days • 62% never met 25 kcal/kg/day goal Hartl R, Gerber L, Ni Q, Ghajar J. Effect of Early Nutrition on Deaths Due to Severe Traumatic Brain Injury. Journal of Neurosurgery. 2008;109:50-56.

  17. Early Nutrition, Contd. • Two week mortality higher if not fed within 5 to 7 days • Two week mortality highest in patients never fed • Mortality rate significantly decreased with increased nutritional level Hartl R, Gerber L, Ni Q, Ghajar J. Effect of Early Nutrition on Deaths Due to Severe Traumatic Brain Injury. Journal of Neurosurgery. 2008;109:50-56.

  18. Early Nutrition, Contd. • Increased mortality with prolonged feeds • 2.1x more likely if no feeds for 5 days • 4.1x more likely if no feeds for 7 days • Every 10 kcal/kg decrease within 5 to 7 days resulted 30-40% increased mortality risk HartlR, Gerber L, Ni Q, Ghajar J. Effect of Early Nutrition on Deaths Due to Severe Traumatic Brain Injury. Journal of Neurosurgery. 2008;109:50-56.

  19. Evidence Based Nutrition – Enteral Support • 71 patients • ≥ 72 hours in ICU • TBI • Intracranial Hemorrhage • Subarachnoid Hemorrhage • Brain Tumor • GCS > 3 Zarbock S, Steinke D, Hatton J, Magnuson B, Smith K, Cook A. Successful Enteral Nutritional Support in the Neurocritical Care Unit. Neurocritical Care.2008;9:210-216.

  20. Enteral Support, Contd. • Compared severity of neurologic illness to caloric intake • Mild: GCS >11 • Moderate: GCS 8-11 • Severe GCS 4-7 • Relationship between severity of neurologic illness and caloric intake? Zarbock S, Steinke D, Hatton J, Magnuson B, Smith K, Cook A. Successful Enteral Nutritional Support in the Neurocritical Care Unit. Neurocritical Care.2008;9:210-216.

  21. Enteral Support, Contd. • GCS did not affect % caloric intake • Delays in meeting caloric goals • Delay in initiation of feeds • Delay in tube placement verification • Orders for enteral • Initiate nutrition, obtain goal rate • If residuals, decrease rate Zarbock S, Steinke D, Hatton J, Magnuson B, Smith K, Cook A. Successful Enteral Nutritional Support in the Neurocritical Care Unit. Neurocritical Care.2008;9:210-216.

  22. Evidence Based Nutrition – 6 Month Outcome • 88 patients • 24 hours post TBI • GCS 4-8 • Hospitalized ≥ 1 week • All received standard care for trauma Dhandapani SS, Manju M, Sharma BS, Mahaparta AK. Clinical Malnutrition in severe traumatic brain injury: Factors associated and outcome at 6 months. Indian Journal of Neurotrauma. 2007;4(1):35-39.

  23. 6 Month Outcome, Contd. • Enteral or by mouth nutrition • Initiated as soon as possible • Gradually increased to goal as tolerated • GCS assessed at 3 and 6 months • Good recovery/moderate disability – Favorable • Persistent vegetative state or death – Unfavorable DhandapaniSS, Manju M, Sharma BS, Mahaparta AK. Clinical Malnutrition in severe traumatic brain injury: Factors associated and outcome at 6 months. Indian Journal of Neurotrauma. 2007;4(1):35-39.

  24. 6 Month Outcome, Contd. • 94% patients fed after 7 days, malnourished • Early feeding, 54% malnourished • Unfavorable outcome in 30 of 37 with clinical malnutrition • Unfavorable outcome in 3 of 15 with no clinical malnutrition Dhandapani SS, Manju M, Sharma BS, Mahaparta AK. Clinical Malnutrition in severe traumatic brain injury: Factors associated and outcome at 6 months. Indian Journal of Neurotrauma. 2007;4(1):35-39.

  25. 6 Month Outcome, Contd. • 40% mortality in malnourished • 11% mortality in non-malnourished • TBI most common cause of death and disability in young people Dhandapani SS, Manju M, Sharma BS, Mahaparta AK. Clinical Malnutrition in severe traumatic brain injury: Factors associated and outcome at 6 months. Indian Journal of Neurotrauma. 2007;4(1):35-39.

  26. TBI Complications – Intracranial Pressure • Increases due to increase in cerebrospinal fluid • Damages brain by restricting blood flow • Methods to alleviate pressure: • Ventriculostomy with IVC • Osmotic Diuretic, Mannitol • Hypertonic Saline Solution • Medically Induced Coma, Pentobarbital

  27. Intracranial Pressure, Sodium • Maintained between 140 and 150 mg/dl • Hypernatremia used to reduce cerebral swelling • 2% Saline Solution administered

  28. Hospital, Day 4 • IVC drain placed • Pentobarbital coma initiated • Cooling blanket initiated

  29. Macronutrient Needs – Pentobarbital Coma • Decreased macronutrient needs due to Pentobarbital • Penn-State Critical Non-Obese Formula • Stress Factors 0.8 to 1.0 • 1,623 to 2,029 kcal • 71-85 gm protein (1.0 – 1.2 gm/kg) • 2,133 mL fluid

  30. TBI Complications – Gastric Emptying • Causes delays in gastric emptying • Pentobarbital reduces gastric emptying • Closely monitor residuals • Possible post pyloric feeds if needed

  31. Hospital, Day 8 • Patients temperature spiked • Hypothermia Protocol Initiated • Body temperature decreased to 33°C

  32. Micronutrient Needs – Pentobarbital Coma and Hypothermia Protocol • Decreased temperature further reduced macronutrient needs • Penn-State Critical Non-Obese Formula • Stress Factors 0.9 to 1.0 • 1,125 to 1,250 kcal • 71-92 gm protein (1.0–1.3 gm/kg) • 2,133 mL fluid

  33. Hospital, Day 12 • Hospital shortage of Pentobarbital • Patient changed to Propofol @ 85 ml/hr • Day 13 – Pentobarbital resumed

  34. Hospital, Day 17 • PEG and tracheostomy placed • Hypothermia Protocol Discontinued • Temperature increased to 37.1°C • Intracranial pressure improved • Pentobarbital discontinued • Precedex started

  35. Micronutrient Needs – D/c Coma and Hypothermia Protocol • Mild weight reduction • Increased macronutrient needs • Penn State Critical Non-Obese Formula • Stress Factors 1.0 to 1.2 • 1,992 to 2,390 kcal • 107 to 142 gm protein (1.5–2.0 gm/kg) • 2,133 to 2,844 mL fluid

  36. Hospital, Day 23 - 27 • Day 23 – • Cerebral edema improving • Intracranial pressure resolving • Clamping trials to begin • Day 26 – • IVC drain removed • Day 27 – • Seizures due to drop in Sodium

  37. Weight Status • Weight 59.9 kg • 11.2 kg wt loss since admission • BMI 17.6 • 69% Ideal Body Weight • Increased Kcal and Protein needs

  38. Micronutrient Needs – Severe Weight Loss • Penn State Critical Non-Obese Formula • Stress Factors 1.3 to 1.5 • 2,625 to 3,029 kcal • 118 to 148 gm protein (2.0 to 2.5 gm/kg) • 2,133 to 2,844 mL fluid • Patient fed using Two Cal HN

  39. Hospital Day, 34 • Patient discharged to Kernan rehabilitation facility

  40. Why Nutrition? • Nutrition within 5-7 days after injury reduces mortality • Early nutrition prevents long term malnutrition • Protects brain by providing large amounts of energy during hyperglycolysis and hyperemia

  41. Nutrition Within 1 Week • Associated with reduction in 2 week mortality • Helps meet needs from hypermetabolism, increased protein needs • Prevents loss of protein and glycogen stores • Postponing can result in malnutrition

  42. Long Term Outcomes • Malnutrition after TBI associated with malnutrition 6 months later • Lower GCS, protein and albumin upon admission associated with greater risk of malnutrition • Delayed nutrition, risk of malnutrition increases • Rapid depletion of glycogen and protein stores

  43. PES Statement, Intervention, Goal

  44. PES Statement, Intervention, Goal

  45. PES Statement, Intervention, Goal

  46. Monitoring • Tube feeding tolerance through monitoring residuals • Energy and protein intake through formula selection • Monitor daily weights • Prealbumin levels

  47. TBI Facts • 20-50% of cases result in death • 52,000 people die each year • 85% die within first two weeks

  48. Why Is Nutrition So Important? • Maintains energy balance and cerebral hemostasis • Associated with 2 week mortality reduction • Prevents malnutrition • Better outcomes of survival and disability • Helps prevent muscle wasting and weight loss

  49. Where Is Our Patient Now? • Discharged from Kernanweeks after admission • Recently visited ICU at Sinai Hospital • Walks, Talks, Eats! • Plans to attend outpatient rehab group at Sinai

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