Nutritional
Management of
Traumatic Brain
Injury
Melissa Wolynec
Aramark Dietetic Intern
February 13, 2012
The Patient
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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
The Patient Medically
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Bilateral frontal contusions
• Subarachnoid hemorrhage
• Left temporal contusions
• Swelling of brain
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Monitored with
daily CT scans
Patient History
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No previous medical history
Alcohol user
• No drug or tobacco use
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Appeared well nourished, stable
weight
Appetite prior to admission unknown
No home medications
Patient Weight
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Admission Weight: 71.1 kg
BMI: 20.6
86% IBW
Patient Nutrient Needs
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Penn State Critical Non-Obese Formula
• Stress Factors 1.2 – 1.4
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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
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Fed via NG tube using Glucerna 1.5
The Injury – Traumatic Brain Injury
(TBI)
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Sudden trauma causing damage to brain
• Head violently hits object
• Bump, blow, jolt, fall
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Object pierces through skill into brain
• Bullet
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May experience loss of consciousness or
coma
The Injury, Contd.
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Mild TBI
• Temporary dysfunction of brain cells
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Serious TBI
• Bruising, torn tissues, bleeding, physical
damages to brain
Symptoms of Severe TBI
Increase in
Sleep
Clear Liquid
from Ears or
Nose
Loss of Bladder
Control
Symptoms
Dilated Pupils
Slurred Speech
Agitation /
Combativeness
Seizures
Weakness /
Numbness
Complications
Attention
Depression,
Anxiety
Memory
TBI
Impaired
perception
and touch
Extremity
Weakness
Hearing and
vision loss
Impaired
coordination
and balance
Primary vs. Secondary
Damage
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Primary Damage
• Intracranial hypertension
• Increased cerebrospinal fluid
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Secondary Damage
• Brain swelling
• Damage to brain cells
About TBI
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Ebb, or Initial Phase
• Peaks at 48 to 72 hours
• Subsides after 3 to 4 days
• Decreased metabolism, temperature,
cardiac output, energy expenditure
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Flow, or Secondary Phase
• Increased metabolism and catabolism
• Last few days to few weeks
Metabolic Alterations
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Hormonal changes
• Release of cortisol, epinephrine and
norepinephrine
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Changes in cellular metabolism
• Increased energy expenditure, oxygen
consumption
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Cerebral and Systemic Inflammatory
Response
• Swelling
Metabolic Alterations Contd.
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Increased
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Basal Metabolism
Oxygen Consumption
Glycogenolysis
Hyperglycemia
Results in muscle wasting
Evidenced Based Nutrition –
Early Nutrition
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Database, 24 Level I and II trauma
centers
• Arrival 24 hours after injury
• Glasgow Coma Score (GSC) < 9
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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.
Early Nutrition, Contd.
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Energy requirements estimated at 25
kcal/kg/day
Mortality: death within 2 weeks after TBI
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Initial: 1,818 patients, Final:1,261 patients
• 61% began feeding Days 1-3
• 5% never fed over 7 days
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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.
Early Nutrition, Contd.
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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.
Early Nutrition, Contd.
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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
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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.
Evidence Based Nutrition –
Enteral Support
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71 patients
≥ 72 hours in ICU
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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.
Enteral Support, Contd.
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Compared severity of neurologic
illness to caloric intake
• Mild: GCS >11
• Moderate: GCS 8-11
• Severe GCS 4-7
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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.
Enteral Support, Contd.
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GCS did not affect % caloric intake
Delays in meeting caloric goals
• Delay in initiation of feeds
• Delay in tube placement verification
• Orders for enteral
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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.
Evidence Based Nutrition – 6
Month Outcome
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88 patients
24 hours post TBI
GCS 4-8
Hospitalized ≥ 1 week
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All received standard care for trauma
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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.
6 Month Outcome, Contd.
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Enteral or by mouth nutrition
• Initiated as soon as possible
• Gradually increased to goal as tolerated
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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.
6 Month Outcome, Contd.
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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.
6 Month Outcome, Contd.
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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.
TBI Complications – Intracranial
Pressure
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Increases due to increase in cerebrospinal
fluid
• Damages brain by restricting blood flow
• Methods to alleviate pressure:
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Ventriculostomy with IVC
Osmotic Diuretic, Mannitol
Hypertonic Saline Solution
Medically Induced Coma, Pentobarbital
Intracranial Pressure, Sodium
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Maintained between 140 and 150
mg/dl
Hypernatremia used to reduce
cerebral swelling
2% Saline Solution administered
Hospital, Day 4
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IVC drain placed
Pentobarbital coma initiated
Cooling blanket initiated
Macronutrient Needs –
Pentobarbital Coma
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Decreased macronutrient needs due to
Pentobarbital
• Penn-State Critical Non-Obese Formula
• Stress Factors 0.8 to 1.0
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1,623 to 2,029 kcal
• 71-85 gm protein (1.0 – 1.2 gm/kg)
• 2,133 mL fluid
TBI Complications – Gastric
Emptying
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Causes delays in gastric emptying
Pentobarbital reduces gastric
emptying
Closely monitor residuals
Possible post pyloric feeds if needed
Hospital, Day 8
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Patients temperature spiked
Hypothermia Protocol Initiated
• Body temperature decreased to 33°C
Micronutrient Needs – Pentobarbital
Coma and Hypothermia Protocol
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Decreased temperature further reduced
macronutrient needs
• Penn-State Critical Non-Obese Formula
• Stress Factors 0.9 to 1.0
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1,125 to 1,250 kcal
• 71-92 gm protein (1.0–1.3 gm/kg)
• 2,133 mL fluid
Hospital, Day 12
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Hospital shortage of Pentobarbital
Patient changed to Propofol @ 85
ml/hr
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Day 13 – Pentobarbital resumed
Hospital, Day 17
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PEG and tracheostomy placed
Hypothermia Protocol Discontinued
• Temperature increased to 37.1°C
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Intracranial pressure improved
• Pentobarbital discontinued
• Precedex started
Micronutrient Needs – D/c Coma
and Hypothermia Protocol
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Mild weight reduction
• Increased macronutrient needs
• Penn State Critical Non-Obese Formula
• Stress Factors 1.0 to 1.2
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1,992 to 2,390 kcal
• 107 to 142 gm protein (1.5–2.0 gm/kg)
• 2,133 to 2,844 mL fluid
Hospital, Day 23 - 27
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Day 23 –
• Cerebral edema improving
• Intracranial pressure resolving
• Clamping trials to begin
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Day 26 –
• IVC drain removed
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Day 27 –
• Seizures due to drop in Sodium
Weight Status
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Weight 59.9 kg
11.2 kg wt loss since admission
BMI 17.6
69% Ideal Body Weight
Increased Kcal and
Protein needs
Micronutrient Needs – Severe
Weight Loss
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Penn State Critical Non-Obese Formula
• Stress Factors 1.3 to 1.5
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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
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Patient fed using Two Cal HN
Hospital Day, 34
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Patient discharged to Kernan
rehabilitation facility
Why Nutrition?
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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
Nutrition Within 1 Week
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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
Long Term Outcomes
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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
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.
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.
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.
Monitoring
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Tube feeding tolerance through
monitoring residuals
Energy and protein intake through
formula selection
Monitor daily weights
Prealbumin levels
TBI Facts
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20-50% of cases result in death
52,000 people die each year
85% die within first two weeks
Why Is Nutrition So Important?
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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
Where Is Our Patient Now?
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Discharged from Kernan weeks after
admission
Recently visited ICU at Sinai Hospital
Walks, Talks, Eats!
Plans to attend outpatient rehab group
at Sinai