- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
- Department of Neuronursing, All India Institute of Medical Sciences, New Delhi, India
- Department of Dietetics, All India Institute of Medical Sciences, New Delhi, India
- Department of Neuro-biochemistry, All India Institute of Medical Sciences, New Delhi, India
Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
DOI:10.4103/2152-7806.93858Copyright: © 2012 Dhandapani S. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
How to cite this article: Dhandapani S, Dhandapani M, Agarwal M, Chutani AM, Subbiah V, Sharma BS, Mahapatra AK. The prognostic significance of the timing of total enteral feeding in traumatic brain injury. Surg Neurol Int 14-Mar-2012;3:31
How to cite this URL: Dhandapani S, Dhandapani M, Agarwal M, Chutani AM, Subbiah V, Sharma BS, Mahapatra AK. The prognostic significance of the timing of total enteral feeding in traumatic brain injury. Surg Neurol Int 14-Mar-2012;3:31. Available from: http://sni.wpengine.com/surgicalint_articles/the-prognostic-significance-of-the-timing-of-total-enteral-feeding-in-traumatic-brain-injury/
Background:To study the effect of timing of total enteral feeding on various nutritional parameters and neurological outcome in patients with severe traumatic brain injury (TBI).
Methods:One hundred and fourteen patients, in the age group of 20–60 years, admitted within 24 h of TBI with Glasgow Coma Scale (GCS) 4–8 were enrolled for the study. Nineteen patients who had expired before the attainment of total enteral feeding were excluded from the analysis. Total enteral feeding was attained before 3 days, 4–7 days, and after 7 days in 12, 52, and 31 patients, respectively, depending on gastric tolerance. They were prospectively assessed for various markers of nutrition and outcome was assessed at 3 and 6 months.
Results:Prospective assessment of 67 hospitalized patients at 3 weeks revealed significant differences in anthropometric measurements, total protein, albumin levels, clinical features of malnutrition, and mortality among the three groups. 80% of those fed before 3 days had favorable outcome at 3 months compared to 43% among those fed later. The odds ratio (OR) was 5.29 (95% CI 1.03–27.03) and P value was 0.04. The difference between those fed before 3 days and 4–7 days was not significant at 6 months even though patients fed before 7 days had still significantly higher favorable outcome compared to those fed after 7 days (OR 7.69, P = 0.002). Multivariate analysis for unfavorable outcome showed significance of P = 0.03 for feeding after 3 days and P = 0.01 for feeding after 7 days.
Conclusions:In severe TBI, unfavorable outcome was significantly associated with attainment of total enteral feeding after 3 days and more so after 7 days following injury.
Keywords: Enteral feeding, malnutrition, outcome, traumatic brain injury
Traumatic brain injury (TBI) is the most common cause of death and disability in young people.[
Adult patients within 24 h of TBI, admitted with Glasgow Coma Scale (GCS) 4–8, to the Department of Neurosurgery, AIIMS, New Delhi, from June to December 2005, were enrolled for the study. Patients with age more than 60 years, GCS 3, diabetes mellitus, renal dysfunction, serious systemic injury, and bilateral non-reactive pupils had been excluded.
Standard care given to study patients consisted of ventilation, seizure prophylaxis with Phenytoin, antibiotic prophylaxis with Cefotaxime or Ceftriaxone and Netilmycin (for 3 days), and gastric ulcer prophylaxis with Ranitidine. Mannitol was given to patients with computerized tomography (CT) having evidence of mass effect (for 5 days). Frusemide was added to patients with midline shift (for 3 days). Fluid and electrolyte homeostasis was maintained. Decision regarding surgical decompression was taken according to the mass effect noted in CT and was individualized to each patient.
Enteral feeding was initiated either through nasogastric tube or orally as early as possible depending upon patients’ consciousness, planned extubation, and gastric ileus. One liter of nasogastric tube feed consisted of 750 ml milk, 1 egg, 30 g sugar, 30 ml coconut oil, 30 g corn flour, and 15 g Trophox® nutritional supplement (
The volume of feed was increased gradually according to the gastric tolerance (as per the residual feed on aspirate) and the day of attainment of total enteral feeding was noted. The total enteral feeding was considered to have been attained when patients received at least 50 kcal/kg/d and 2 g/kg protein (16% protein calories). No patient had received parenteral hyperalimentation or albumin supplements. Age, post-resuscitation admission GCS, associated systemic injury, surgical decompression, day of attainment of total enteral feeding, weekly anthropometric and biochemical parameters till 3 weeks, and clinical features of malnutrition at 3 weeks were noted in a pre-planned prospective database and were followed up.
Every week since admission, non-stretchable inch tape and McGay caliper were used to measure mid-arm circumference (MAC) and triceps skin fold thickness (TSF), respectively, of hospitalized patients, over the midpoint of the nondominant arm between the acromion and olecranon processes, with the forearm flexed at 90°, and the mean of three measurements was recorded. Mid-arm muscle circumference (MAMC) was calculated from MAC and TSF using the formula: MAMC (cm) = MAC (cm) – [3.14 × TSF (cm)]. MAMC and TSF are indicators of somatic protein and fat reserves, respectively.
Serum total protein indicates overall nutritional status, whereas serum albumin and urine creatinine are biochemical markers of visceral protein anabolism and somatic protein reserve, respectively. Percent creatinine excretion in comparison to expected value (men 23 mg/kg, women 18 mg/kg) is an estimate of chronic protein status. Serum albumin and total protein levels were tested by bromcresol green dye binding method and biuret method, respectively, using Beckman Synchron CX5 Delta Clinical System (GMI Inc., MN, USA). Urine creatinine levels were tested by Jaffe's colorimetric method, using Hitachi 717 auto-analyzer (GMI Inc.).
The primary outcome was Glasgow Outcome Scale (GOS)[
SPSS software (version 10, SPSS Inc., Chicago, IL, USA) was used for the statistical analyses. Continuous variables in two groups were compared by using independent-samples t-test. Continuous variables in more than two groups were compared by using one-way analysis of variance (ANOVA). Proportions were compared by using chi-square tests or Fisher's exact test, wherever appropriate. Subgroup analyses were done using Breslow-Day test of homogeneity of odds ratios (ORs). Multivariate analysis was conducted with logistic regression, adjusting for age, admission GCS, associated minor systemic injury, surgical intervention, and the day of attainment of total enteral feeding. Two-sided significance tests were used throughout, and the significance level was kept at P ≤0.05.
From June to December 2005, 114 patients who fulfilled the eligibility criteria were enrolled for the study. Nineteen patients, who had expired before the attainment of total enteral feeding, were excluded from all analyses. Total enteral feeding was attained earlier than 3 days, 4–7 days, and later than 7 days in 12, 52, and 31 patients, respectively, depending on gastric tolerance. Out of these 95 patients, who were taken up for the analysis, 67 hospitalized patients were prospectively assessed weekly till 21 days for various secondary outcome parameters; the other 19 were discharged and 9 patients expired before 21 days. Primary outcome assessment was done at 3 and 6 months in 68 and 53 patients, respectively, either directly or over telephone.
The baseline characteristics of patients grouped according to the day of attainment of total enteral feeding are as shown in
The anthropometric, biochemical, and clinical markers of malnutrition from admission till 3 weeks in different groups are as shown in
The percent fall in MAC and MAMC values was significantly greater in those fed 4–7 days (12 and 8%, respectively) and even more among those fed later than 7 days (17 and 15%, respectively) (P = 0.001). The fall in TSF values, though similar, was not significant. The total protein (mean values: 7.3, 6.6, and 5.9 g/dl) and albumin levels (mean values: 3.3, 3.1, and 2.8 g/d) showed significant differences proportionate to the delay in attainment of total enteral feeding (P ≤ 0.005). Urinary creatinine and percent creatinine excretion had similar falling values which were not statistically significant.
The presence of clinical features of malnutrition (edema, skeletal prominence, or cheilosis) at 3 weeks was significantly associated with total enteral feeding after 7 days with OR 6.2 (95% CI 1.3–30.2) and P value 0.01. Feeding after 7 days also showed significant association with mortality at 3 weeks with OR 4.5 (95% CI 1.7–11.8) and P value 0.001.
The GOS at 3 and 6 months in various groups are shown in
Logistic regression analysis was performed adjusting for age, admission GCS, associated minor systemic injury, surgical intervention, and timing of total enteral feeding. As shown in
Nutritional demand in patients with severe TBI is increased due to hypermetabolism and increased protein catabolism.[
Nutritional support can be provided by both enteral and parenteral routes, depending on the medical circumstances. The advantage of enteral nutrition is that it is more physiological, has fewer complications, is less expensive, and is associated with rapid normalization of nutritional status, improved immune function, decreased likelihood of gut absorption disturbances, reduced incidence of sepsis, and reduced length of hospital stay.[
In a prospective, randomized controlled trial (RCT), Rapp et al. (1983) reported a significantly higher 18-day mortality rate (8/18) in enterally fed patients as compared to early total parenteral nutrition (TPN) (0/20).[
Yanagawa et al., in a meta-analysis (2002), noted that early feeding (either enteral or parenteral) was associated with a trend toward better outcome in terms of survival and disability.[
In the present study, nutritional status of patients during hospital stay was assessed weekly from admission till 21 days and the outcome was assessed at 3 and 6 months. Patients with GCS score 3 were not included due to the very high mortality as per literature and observation.[
The study also shows significant influence of the timing of total enteral feeding on anthropometric measurements such as MAC and MAMC which are indirect estimates of somatic protein reserves.[
The unfavorable outcome in patients who had delayed enteral feeding also implies the possible necessity of parenteral nutritional replacement if gastric atony prevents enteral feeding more than 7 days. The basis for improved neurological recovery and survival rate in the early total enteral feeding group may be because of improved nutrition maintained during the initial phase of injury preventing the effects of hypermetabolism and increased protein catabolism. The antioxidant minerals and vitamins in the enteral feed might have reduced lipid peroxidation caused by free radicals accumulated due to low cellular adenosine triphosphate (ATP). Further RCTs are needed to confirm the improved outcome seen among those who received total enteral feeding earlier than 3 days following injury.
Different nutrition formulations in patients with TBI have not yielded much except for the effect of high protein content (15% nitrogen calories).[
The Institute of Medicine (IOM) committee report found the majority of clinical guidelines for TBI not to specifically address optimal nutritional support for TBI.[
In summary, among patients with severe TBI, delayed attainment of total enteral feeding was found to have significant association with anthropometric, biochemical, and clinical markers of nutritional depletion. Also, unfavorable neurological outcome was significantly associated with attainment of total enteral feeding after 3 days and more so after 7 days following injury.
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