Nutritional Considerations in Clinical Treatment: The Perspective of a Neurosurgeon

Traumatic brain injury (TBI) remains a highly lethal injury with mortality ranging from 20-50 percent (Bulger et al., 2002; Demetriades et al., 2004; Jiang et al., 2002). Approximately 52,000 patients die from TBI each year (Sosin et al., 1995; Thurman et al., 1999) with approximately 85 percent of the deaths occurring within the first two weeks (Roberts et al., 2004). TBI pharmaceutical trials have failed to demonstrate any efficacy in reducing deaths (Narayan et al., 2002). Proper trauma transport systems and maintenance of cerebral perfusion and oxygenation by avoidance of hypoxemia, arterial hypotension and intracranial hypertension reduces mortality and improves outcome (Brain Trauma Foundation, 2000; Chesnut et al., 1993; Härtl et al., 2006; Sampalis et al., 1999; Smith et al., 1990). Currently, the metabolic status and nutritional needs of TBI patients are less of a priority than maintaining cerebral perfusion. However, TBI results in a hypermetabolic and catabolic state that increases systemic and cerebral energy requirements (Clifton et al., 1986; Deutschman et al., 1986; Hovda et al., 1995; Weekes and Elia, 1996). A recent review from the Cochrane Collaboration states that early feeding may be associated with a trend towards better outcomes after TBI (Perel et al., 2006). The “Guidelines for the Management of Severe Traumatic Brain Injury” recommend that the patient’s feeding requirements should be met by the end of the first week after TBI (Brain Trauma Foundation, 2000). These recommendations were based on two small, randomized trials (Rapp et al., 1983; Taylor et al., 1999). There are no studies on the relationship of mortality to the amount and frequency of feeding in TBI patients. In the few studies done, none controlled for factors known to affect mortality from TBI, such as hypotension, age, pupillary status, and CT scan findings. The Brain Trauma Foundation (BTF) prospectively collects data on preand inhospital TBI management in 20 Level I and 2 Level II trauma centers in New York State as part of a TBI quality improvement program. An analysis was conducted examining the effect of timing and quantity of nutritional support on early mortality. Early onset of nutritional support and amount of nutritional support was hypothesized to be associated with a reduced mortality at two weeks. In addition, a feeding compliance implementation program was undertaken at one of the participating hospitals to increase the net caloric intake of patients.