Early Enteral Nutrition And Clinical Outcomes In Acute Stage Of Severe Traumatic Brain Injury

Abstract

Brain trauma; Brain injuries are a primary cause of disability. A Brain injury may result from numerous external and internal mechanisms and the functional consequences differ depending on the severity of injury and the site of lesion. Even if the severity of injury and lesion site are known, the resultant impairments are often unique and unpredictable. Nutrition; The use of nutrition in treating diseases isn't a new born concept. However the term "Dietetics" wasn't introduced until the 19th century, where nutrition is now considered one of the basic fundamentals in the management of critically ill patients. It is well established that early enteral feeding support during critical illness decreases length of stay in the intensive care unit (ICU), disease severity, time of mechanical ventilation, morbidity and mortality as well as maintains gut barrier. Malnutrition is one of the most complicated challenges that critical care physicians might face in ICU. Many physiologic changes occur in response to stress leading to increase in protein catabolism, decrease in lean body mass thus leading to increase in infection rate and wound dehiscence. Although current guidelines support the use of nutritional therapy in critically ill patients, many ICU patients still receive inadequate feeding. Enteral Nutrition; Gastrointestinal tract is the major organ of digestion and absorption, barrier against bacteria and toxins as well as major secretion site of immune globulins, especially IgA. Maintaining that barrier through enteral feeding will stimulate intestinal growth and function, directly by supplying substrates for enterocyte oxidation and indirectly by promoting hormonal secretion which all together prohibit bacterial translocation and decrease rate of infection. Enteral nutrition (EN) should be initiated early (within 48 hours) from the time of admission to ICU in patients who are unable to maintain oral intake independently. Although EN should provide 25 to 30 kcal/kg/day and 1-2 g/kg/day protein to most critically ill patients, nutritional support should also be adjusted according to patient's overall clinical status and body habits. For instance, morbidly obese patients should receive less total caloric intake (between 14 to 18 kcal/kg/day and 2.5 g/kg/day protein). Total Parenteral Nutrition; TPN, developed in the 1960s, is mostly indicated when enteral or oral routes cannot provide adequate nutrients to patients. It is delivered via central vein bypassing the gastrointestinal tract. The choice of whether to initiate TPN, EN or both in critical care patients had been a dilemma. However, a recent trial showed higher morbidity and mortality rate in patients receiving TPN with EN as compared to EN alone. Also, TPN is associated with several complications such as catheter related infections, catheter venous thrombosis, immune suppression and gastrointestinal atrophy. It should be considered very cautiously when other route of feeding is impossible. Early enteral nutrition in head trauma patients; Most investigators agree that aggressive nutritional support, starting within 48 hours of admission to the ICU, maximizes survival rates in head trauma patients. Early enteral nutrition (EN) started within 48 h post-injury reduces clinical malnutrition, prevents bacterial translocation from the gastrointestinal tract and improves outcome in sTBI patients sustaining hypermetabolism and hypercatabolism. The EN patients had a greater survival rate and GCS score on the 7th day in the intensive care unit (ICU) and a better outcome at 1 month post-injury.