Role of early enteral nutrition in severe head injury

Effect of Early Enteral Nutrition Effect of Early Enteral Nutrition on Outcome in Severely Head on Outcome in Severely Head

Injured PatientsInjured Patients

A Prospective Controlled StudyA Prospective Controlled Study

Yamini Tiwari, Deepak AgrawalYamini Tiwari, Deepak AgrawalDepartment of Dietetics and *Neurosurgery Department of Dietetics and *Neurosurgery Neurosciences centre, All India Institute of Neurosciences centre, All India Institute of

Medical Sciences, New DelhiMedical Sciences, New Delhi

Early Enteral Feeding in Severe Head Injury

BACKGROUNDBACKGROUND

Daily Caloric requirements in severe Daily Caloric requirements in severe HI= severe burnsHI= severe burns

Has been estimated to range from Has been estimated to range from 150-250% of RME150-250% of RME

Protein requirements have been Protein requirements have been estimated at 1.5-2.0g/Kg/dayestimated at 1.5-2.0g/Kg/dayClifton GL, Robertson CS, Choi SC. Assessment of nutritional Clifton GL, Robertson CS, Choi SC. Assessment of nutritional requirements of head injured patients. J Neurosurg 1986;64:895-requirements of head injured patients. J Neurosurg 1986;64:895-901.901.


BACKGROUNDBACKGROUND

Trauma

Systemic Inflammatory

Response

INFECTION(Sepsis, Pneumonia, Meningitis)

UnregulatedHypermetabolism

Multiple Organ Failure

Protein CalorieMalnutrition


PATHOGENESISPATHOGENESIS

Ott L, McClain CJ, Gillespie M, et al. Cytokines and metabolic dysfunction after severe head injury. J Neurotrauma. 1994;11:447-72.

Starts on Day 1


CURRENT STATUSCURRENT STATUS Seven trials have studied the effect of Seven trials have studied the effect of

nutrient administration on outcome in nutrient administration on outcome in severe HIsevere HI

Most studies have compared parentral Most studies have compared parentral with enteral feedingwith enteral feeding

Cochrane review concluded that Cochrane review concluded that although early nutrition results in better although early nutrition results in better outcome, further trials are neededoutcome, further trials are neededYanagawa T, Bunn F, Roberts I, Wentz R, Pierro A. Nutritional Yanagawa T, Bunn F, Roberts I, Wentz R, Pierro A. Nutritional support for head-injured patients. support for head-injured patients. Cochrane Database Syst Cochrane Database Syst Rev. 2002Rev. 2002;(3):CD001530. ;(3):CD001530.


INDIAN SCENARIOINDIAN SCENARIO

No comparable Indian studies.No comparable Indian studies. Adult pts are kept NPO for a variable Adult pts are kept NPO for a variable

period (3 days to 2 weeks)period (3 days to 2 weeks) Usually on 2.5L of DNS/day (500Kcal)Usually on 2.5L of DNS/day (500Kcal) Attempts to calculate caloric or protein Attempts to calculate caloric or protein

requirements for individual pts lackingrequirements for individual pts lacking Standard feed of 2500 Kcal / 50g Standard feed of 2500 Kcal / 50g

Protein is given in adult patientsProtein is given in adult patients


AIMS & OBJECTIVESAIMS & OBJECTIVES

To study and compare outcomes To study and compare outcomes following early following early and adequateand adequate enteral enteral feeding vis-à-vis late initiation of feeding vis-à-vis late initiation of feeding in patients with severe head feeding in patients with severe head injuries injuries


STUDY DESIGNSTUDY DESIGN

Prospective controlled studyProspective controlled study

5 month period5 month period


MATERIALS & METHODSMATERIALS & METHODS

INCLUSION CRITERIAINCLUSION CRITERIA Patients with severe HI (GCS ≤ 8)Patients with severe HI (GCS ≤ 8) Duration from injury <12 hoursDuration from injury <12 hours

EXCLUSION CRITERIAEXCLUSION CRITERIA Polytrauma (except long bone #)Polytrauma (except long bone #) Pts who died within 48 hrs of injuryPts who died within 48 hrs of injury



TEST GROUPTEST GROUP Pts had enteral feeding (through Ryles Pts had enteral feeding (through Ryles

tube) started within 48 hours of injurytube) started within 48 hours of injury caloric requirements were calculated using caloric requirements were calculated using

the Harris-Benedict formula.the Harris-Benedict formula. Kcal/day= BMR X Activity factor (2 in Kcal/day= BMR X Activity factor (2 in

severe HI)severe HI) Men: BMR = 66 + (13.7 X wt in kg) + (5 X Men: BMR = 66 + (13.7 X wt in kg) + (5 X

ht in cm) - (6.8 X age in years)ht in cm) - (6.8 X age in years) Protein intake at 1.8g/kg/dayProtein intake at 1.8g/kg/day



CONTROL GROUPCONTROL GROUP Enteral feeding started in a delayed Enteral feeding started in a delayed

manner, based on currently manner, based on currently prevailing practices and decisions of prevailing practices and decisions of the treating neurosurgeons the treating neurosurgeons



OUTCOME ASSESSMENTOUTCOME ASSESSMENT Outcome was assessed using Outcome was assessed using

Glasgow outcome score Glasgow outcome score (GOS) at 4 weeks post-injury (GOS) at 4 weeks post-injury or death, whichever came or death, whichever came earlier.earlier.

Good outcomeGood outcome:GOS 4-5:GOS 4-5 Poor outcomePoor outcome:: GOS 1-3GOS 1-3

Jennett B, Bond M. Assessment of outcome Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet after severe brain damage. Lancet 1975;1(7905):480-41975;1(7905):480-4

GOSGOS

11 DeathDeath

22 VegetativeVegetative

33 severe severe disabilitydisability

44 Moderate Moderate disabilitydisability

55 Good Good recoveryrecovery



Pts were enrolled into a control or a Pts were enrolled into a control or a

test group, depending upon the call-test group, depending upon the call-

day.day.


RESULTSRESULTS

Total RecruitmentTotal Recruitment

Test Group Test Group 17 pts17 pts

Control GroupControl Group 20 pts20 pts

Test

Control

Patients


RESULTSRESULTS

Mean admission GCSMean admission GCS Test groupTest group 5.8 (range 3-8)5.8 (range 3-8)

Control grpControl grp 5.2 (range 3-8)5.2 (range 3-8)

Test

Control

Patients


RESULTSRESULTS

Surgical InterventionSurgical Intervention

Test GroupTest Group 14 pts (82.3%)14 pts (82.3%)

Control GrpControl Grp 18 pts (85%)18 pts (85%)

Test

Control

Patients


RESULTSRESULTS

Time to Enteral feeding (From Time to Enteral feeding (From

Injury)Injury)

Test GroupTest Group 40 hrs40 hrs

(range 12-48 hrs)(range 12-48 hrs)

Control GroupControl Group 7.1 days7.1 days

(range 48-336 hrs) (range 48-336 hrs)

Test

Control

Patients


OUTCOME (GOS)OUTCOME (GOS)

24

40

0

50

41

10

18

0

18

00

10

20

30

40

50

60

Perc

enta

ge

Death Vegetative Severe Moderate Good

Test Control


RESULTS (OUTCOME)RESULTS (OUTCOME)

Poor Outcome Poor Outcome (GOS 1-3)(GOS 1-3)

Test GroupTest Group 61.1% 61.1% (n=11)(n=11)

Control groupControl group 100% 100% (n=20)(n=20)(p=0.005)(p=0.005) Patients


RESULTSRESULTS

Good OutcomeGood Outcome (GOS 4 & (GOS 4 & 5)5)

Test GroupTest Group 35.3% 35.3% (n=6)(n=6)

Control grpControl grp 0% (n=0) 0% (n=0)

Test

Control

Patients


CONCLUSIONSCONCLUSIONS

This study shows that early and This study shows that early and appropriate nutritional support can play appropriate nutritional support can play a pivotal role in improving outcome in a pivotal role in improving outcome in severely head injured patients.severely head injured patients.

Early nutrition support may be Early nutrition support may be improving outcome by: decreasing improving outcome by: decreasing infection infection (Pneumonia/meningitis/septicemia) & (Pneumonia/meningitis/septicemia) & Preventing MOFPreventing MOF


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Role of early enteral nutrition in severe head injury