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Return to Early Nutrition Critical to Survival Following Traumatic Brain Injury Overview

More on Early Nutrition Critical to Survival Following Traumatic Brain Injury

Early Nutrition Critical to Survival Following Traumatic Brain Injury

New York (Jun 15, 2009)

Brain scans

A recent study by New York-Presbyterian neurosurgeon Dr. Roger Härtl and colleagues shows that providing early nutrition following a brain injury is vital.

Traumatic brain injury (TBI) is the leading cause of death and disability in people ages 1 to 44. Although care of these patients has improved dramatically since "best practice" guidelines were established in 1995, the treatments have focused on relieving intracranial pressure, hypotension, hypoxia, and avoiding steroids. The nutrients patients receive in the first few days following their injury have never been considered as important.

Dr. Härtl and his colleagues chanced upon the significance of nutrition as they were analyzing data from a New York State trauma-center compliance study of TBI guidelines. As they sifted through six years of data from the care of 797 patients, this finding leapt out, Dr. Härtl said. "We found almost a linear relationship between nutrition and mortality." In other words, patients who did not receive gastric feeding within the first five days of their injury were twice as likely to die from their brain injury, and those who did not receive feeding within seven days were four times as likely to die.

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Previous nutrition recommendations said that patients should receive 140 percent of their normal caloric intake within seven days of the TBI (100 percent for patients who were paralyzed). Dr. Härtl's study showed that, not only is it better to administer nutrients to patients as early as possible, but also that the more nutrients they get the better. The best outcomes were in patients who received a minimum of 25kcal/kg each day. For every 10kcal/kg decrease in caloric intake, the mortality rate increased 30 to 40 percent.

Reaching patients' minimum caloric requirement is sometimes complicated, said Dr. Härtl, because the activity of their intestinal system may be so slowed. "If you feed gastric or enteral nutrition to patients without peristalsis it's just not being transported – you can't really get it into them." In these cases the trauma team stimulates peristalsis and gastric motility medically. "Sometimes one can circumvent this by giving parenteral, intravenous nutrition, and that is safe; however, there is some concern about infection," he said.

Brain in Overdrive

PET and metabolic studies have shown that a severe traumatic injury sends the brain into a hypermetabolic state, said Dr. Härtl, a possible explanation for its dramatic energy requirements. "Within the first few days of the injury everything is running full speed, but at the same time there appears to be a dysfunction of the mitochondria. So the brain's disproportional increase in energy requirements may be due to the fact that it is not metabolizing the energy properly."

Any type of trauma to the body can also result in a post-traumatic stress response, he said, which is associated with an increased rate of infection. Studies have shown that if patients with other types of trauma receive nutrients early on after their injury, the stress response is blocked and the infection and mortality rates both decrease as well.

Roger Hartl, M.D
Roger Härtl, M.D.
(photo: Weill Cornell
Medical College)

Since the study was designed to look at compliance, Dr. Härtl and his colleagues were able to follow patients for only a short period following an injury; their endpoint was survival at two weeks. "This is a very crude parameter of outcome obviously," he said. "But studies have shown that if you do anything to decrease mortality – treat intracranial pressure very aggressively, avoid hypotension – you also improve outcome. So we're not just shifting the patients who would have died into a vegetative state, but actually really increasing overall the quality of survival."

Initial Transport Crucial

The database held another surprise, Dr. Härtl said, namely just how important the initial transport decision was. "If TBI patients were not brought directly to a level 1 trauma center, but were brought to a community hospital first and to a trauma center later, they tended to have a poorer outcome." Level 1 trauma centers provide better care for TBI patients, he said, because they have neurosurgeons available around the clock, they have a CT scanner that's functional around the clock, a trauma team, and a trauma bay. Patients are immediately greeted by the trauma team when they arrive.

"But not all trauma centers are equal in terms of the care they provide to TBI patients," he added. "In New York City we have 18 level 1 trauma centers, and everyone takes care of head injury patients, and this is a big problem. The mortality within the trauma centers in the city is relatively high, and guideline compliance is not very high." Dr. Härtl said he hopes to gather additional data to demonstrate that having one or two trauma centers in New York City that are really well equipped and well trained to take care of head injury patients would be a much more efficient and effective approach.

Roger Härtl, MD is an Attending Neurological Surgeon at NewYork-Presbyterian Hospital/Weill Cornell Medical Center, and the Chief of Spinal Surgery at Weill Cornell Medical College.

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