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: 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
Sudden: Head violently hits object - Bump, blow, jolt, fall
Pierces: Bullet

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

9. Symptoms of Severe TBI Symptoms Increase in Sleep
Loss of Bladder Control
Slurred Speech
Agitation / Combativeness
Weakness / Numbness
Seizures
Dilated Pupils
Clear Liquid from Ears or Nose

10. Impaired coordination and balance
Complications
TBI
Attention
Memory
Extremity Weakness
Impaired coordination and balance
Hearing and vision loss
Impaired perception and touch
Depression, Anxiety

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 Flow, or Secondary 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
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.

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:

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:

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:

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
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.

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 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 – Day 26 – Day 27 –
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
Problem: Increased nutrient needs (NC – 5.1)
Etiology: Head Trauma
Sign/Symptoms: CT scan showing swelling, bifrontal contusions, subarachnoid hemorrhage and left temporal contusions.
Interventions
#1. Insert enteral feeding tube (ND-2.1.2)
Recommend to insert NG tube to allow for tube feeding of intubated patient.
#2. Formula/Solution (ND-2.1.1)
Recommend a calorically dense formula to provide adequate calories and protein.
Goal
Short-term: To initiate tube feeding. To tolerate tube feeding at goal rate.
Long-term: To transition to solid food once extubated.

44. PES Statement, Intervention, Goal
Problem: Decreased Nutrient Needs (NI – 5.4)
Etiology: Patient with medically induced coma, hypothermia protocol
Sign/Symptoms: Currently on pentobarbital with temperature of 33°C.
Interventions
#1. Formula/Solution (ND-2.1.1)
Recommend to reduce tube feeding rate based on recalculated needs to a lower rate, providing fewer calories and protein.
Goal
Short-term: To decrease tube feeding rate. To tolerate tube feeding at goal rate.
Long-term: To maintain weight and protein stores.

45. PES Statement, Intervention, Goal
Problem: Swallowing difficulty (NI – 1.1)
Etiology: Patient currently intubated
Sign/Symptoms: Need for tube feeding.
Interventions
#1. Insert enteral feeding tube (ND-2.1.2)
Recommend to insert NG tube to allow for tube feeding of intubated patient.
Goal
Short-term: To initiate tube feeding. To tolerate tube feeding at goal rate.
Long-term: If not extubated, to obtain a PEG tube.

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 Kernan weeks after admission
Recently visited ICU at Sinai Hospital
Walks, Talks, Eats!
Plans to attend outpatient rehab group at Sinai