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Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel (2011)

Chapter:Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury

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Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
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B
Evidence-Based Guidelines for Traumatic Brain Injury

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

TABLE B-1 Content of Evidence-Based Guidelines (EBG) for Acute Traumatic Brain Injury (TBI) in Intensive Care Unit (ICU) Setting (e.g., Critical Illness)

Guideline/Step of Care Process with Nutrition Implications

Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injurya

American Society for Parenteral and Enteral Nutrition Critically Ill Patientb

Nutrition-related assessment information

 

A1. Traditional nutrition assessment tools (albumin, pre-albumin, and anthropometry) are not validated in critical care. Before initiation of feedings, assessment should include evaluation of weight loss and previous nutrient intake prior to admission, level of disease severity, comorbid conditions, and function of the gastrointestinal (GI) tract. (Grade: E)

 

C1. The target goal of enteral nutrition (EN) (defined by energy requirements) should be determined and clearly identified at the time of initiation of nutrition support therapy. (Grade: C) Energy requirements may be calculated by predictive equations or measured by indirect calorimetry. Predictive equations should be used with caution, because they provide a less accurate measure of energy requirements than indirect calorimetry in the individual patient. In the obese patient, the predictive equations are even more problematic without availability of indirect calorimetry. (Grade: E)

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

American Dietetic Association—Critical Illnessc

American Association of Neuroscience Nurses—Nursing Management of Adults with Severe TBId

CI: Indirect calorimetry to determine RMR

Indirect calorimetry is the standard for determination of resting metabolic rate (RMR) in critically ill patients because RMR based on measurement is more accurate than estimation using predictive equations.

 

 

Rating: Strong

Imperative

 

CI: RMR Predictive equations for nonobese patients

If predictive equations are needed in nonobese, critically ill patients, consider using one of the following, as they have the best prediction accuracy of equations studied (listed in order of accuracy): Penn State, 2003a (79%), Swinamer (55%), and Ireton-Jones, 1992 (52%). In some individuals, errors between predicted and actual energy needs will result in under- or over-feeding.

 

 

Rating: Fair

Conditional

 

CI: Inappropriate RMR predictive equations for this population

The Harris-Benedict (with or without activity and stress factors), the Ireton-Jones, 1997, and the Fick equations should not be considered for use in RMR determination in critically ill patients, because these equations do not have adequate prediction accuracy. In addition, the Mifflin-St. Jeor equation should not be considered for use in critically ill patients, as it was developed for healthy people and has not been well researched in the critically ill population.

 

 

Rating: Strong

Imperative

 

CI: RMR predictive equations for obese patients

If predictive equations are needed for critically ill, mechanically ventilated individuals who are obese, consider using Ireton-Jones, 1992 or Penn State, 1998, because they have the best prediction accuracy of equations studied. In some individuals, errors between predicted and actual energy needs will result in under- or over-feeding.

 

 

Rating: Fair

Conditional

 

CI: Rest periods and RMR

Allow a rest of 30 minutes prior to RMR measurement in critically ill patients.

 

 

Rating: Consensus

Imperative

 

CI: Rest period and accuracy of RMR

If the critically ill patient has undergone a nursing activity or medical procedure (e.g., suctioning, wound care, central venous access or ventilator setting change), then employ a 30-minute rest after procedures to achieve a resting state during RMR measurement. Measuring RMR before the 30-minute period may be inaccurate because patient instability or ventilator gas re-equilibration.

 

 

Rating: Consensus

Conditional

 

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

Guideline/Step of Care Process with Nutrition Implications

Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injurya

American Society for Parenteral and Enteral Nutrition Critically Ill Patientb

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

American Dietetic Association—Critical Illnessc

American Association of Neuroscience Nurses—Nursing Management of Adults with Severe TBId

CI: Impact of environmental factors on RMR

Ensure that the room is comfortably quiet, and the light is not providing heat or discomfort for the patient. Noise and light may cause erroneous measures of RMR if the critically ill patient’s state of rest is disturbed.

 

 

Rating: Consensus

Imperative

 

CI: Impact of room temperature on RMR

Recommend a room temperature 20 to 25 degrees Celsius (68 to 77 degrees Fahrenheit). When the room’s temperature is too cold, RMR is overestimated in critically ill patients by shivering or non-shivering thermogenesis, as the body adapts.

 

 

Rating: Weak

Imperative

 

CI: Environmental factors and RMR

Ensure that each critically ill patient is in a physically comfortable posture before proceeding with the test, because discomfort will result in erroneously high RMR measures. Make sure that repeated measures are taken in the same position to ensure comparability of data.

 

 

Rating: Insufficient Evidence

Imperative

 

CI: Steady state measurement of RMR

For ventilated patients, if a steady state is achieved, then a single measure is adequate to describe RMR. To achieve a steady state, discard the first five minutes of measurement. Then achieve a five-minute period with CV = 5% for oxygen consumption and carbon dioxide production. An alternate protocol can be 25 minutes in duration if a CV of 10% is achieved. If proper attention is given to achieving resting conditions, 80% or more of RMR measures in ventilator patients will be in steady state. Sedation improves the likelihood of obtaining steady state measures.

 

 

Rating: Strong

Imperative

 

CI: Non-steady state measurement conditions

There are published data that were not in steady state, but were still reasonably close to steady state measures. When steady state is not achieved, interpret the results carefully. If the non-steady state conditions are chronic (e.g., patient posturing), then higher measures may reflect actual energy expenditure. If non-steady state conditions are episodic (e.g., ventilator change, nursing intervention, anxiety, coughing, sneezing, movement), RMR measures should be taken at a separate time.

 

 

Rating: Consensus

Conditional

 

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

Guideline/Step of Care Process with Nutrition Implications

Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injurya

American Society for Parenteral and Enteral Nutrition Critically Ill Patientb

Specific nutrition interventions

Level II. Patients should be fed to attain full caloric replacement by day 7 postinjury

A2. Nutrition support therapy in the form of enteral nutrition (EN) should be initiated in the critically ill patient who is unable to maintain volitional intake. (Grade: C)

Data show that starved traumatic brain injury (TBI) patients lose sufficient nitrogen to reduce weight by 15% per week; 100 to 140% replacement of Resting Metabolism Expenditure with 15 to 20% nitrogen calories reduces nitrogen loss. Data in non-TBI injured patients show that a 30% weight loss increased mortality rate. The data support feeding at least by the end of the first week. It has not been established that any method of feeding is better than another or that early feeding prior to 7 days improves outcome. Based on the level of nitrogen wasting documented in TBI patients and the nitrogen sparing effect of feeding, it is a Level II recommendation that full nutritional replacement be instituted by day 7 postinjury.

A3. EN is the preferred route of feeding over parenteral nutrition (PN) for the critically ill patient who requires nutrition support therapy. (Grade: B)

A4. Enteral feeding should be started early within the first 24–48 hours following admission. (Grade: C) The feedings should be advanced toward goal over the next 48–72 hours. (Grade: E)

A5. In the setting of hemodynamic compromise (patients requiring significant hemodynamic support including high dose catecholamine agents, alone or in combination with large volume fluid or blood product resuscitation to maintain cellular perfusion), EN should be withheld until the patient is fully resuscitated and/or stable. (Grade: E)

A6. In the ICU patient population, neither the presence nor absence of bowel sounds nor evidence of passage of flatus and stool is required for the initiation of enteral feeding. (Grade: B)

A7. Either gastric or small bowel feeding is acceptable in the ICU setting. Critically ill patients should be fed via an enteral access tube placed in the small bowel if at high risk for aspiration or after showing intolerance to gastric feeding. (Grade: C) Withholding of enteral feeding for repeated high gastric residual volumes alone may be sufficient reason to switch to small bowel feeding (the definition for high gastric residual volume is likely to vary from one hospital to the next, as determined by individual institutional protocol). (Grade: E)

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

American Dietetic Association—Critical Illnessc

American Association of Neuroscience Nurses—Nursing Management of Adults with Severe TBId

CI: Respiratory quotient

If Respiratory Quotient (RQ) is below 0.7 or above 1.0, then repeated measures are necessary under more optimal conditions. An RQ under 0.70 suggests hypoventilation (inadequate removal of metabolic carbon dioxide from the blood to the lung) or prolonged fasting. An RQ above 1.0, in the absence of overfeeding, suggests hyperventilation (removal of carbon dioxide from the blood to the lung in excess of the amount produced by metabolism) or inaccurate gas collection.

 

 

Rating: Strong

Conditional

 

CI: Enteral vs. parenteral nutrition

If the critically ill ICU patient is hemodynamically stable with a functional GI tract, then EN is recommended over PN. Patients who received EN experienced less septic morbidity and fewer infectious complications than patients who received PN. In the critically ill patient, EN is associated with significant cost savings when compared to PN. There is insufficient evidence to draw conclusions about the impact of EN or PN on length of stay (LOS) and mortality.

Administering intensive insulin therapy may reduce intercranial pressure (ICP) (Level 3)

Isolated patients with severe TBI treated with intensive insulin therapy had lower mean and maximal ICPs than subjects in a randomized control group who were treated with insulin only when their glucose levels exceeded 220 mg/dl. The intensive insulin therapy group did not experience more hypoglycemic episodes and required less vasopressors to achieve the same cerebral perfusion pressure as the control group.

 

Rating: Strong

Conditional

CI: Timing of enteral nutrition

If the critically ill patient is adequately fluid resuscitated, then EN should be started within 24 to 48 hours following injury or admission to the ICU. Early EN is associated with a reduction in infectious complications and may reduce LOS. The impact of timing of EN on mortality has not been adequately evaluated.

 

Rating: Strong

Conditional

Initiating adequate nutrition within 72 hours of injury may improve outcomes (Level 3)

A study of the effect of malnutrition on rehabilitation length of stay found that patients with malnutrition had lengths of stay that were 28 days longer than patients with adequate nutrition. Two systematic reviews found a trend toward improved mortality and less disability with early feeding in patients with severe TBI. The BTF Guidelines for the Management of Severe TBI recommend patients be fed so that full caloric requirements are met by postinjury day 7 (Bratton et al., 2007).

CI: Immune-enhancing enteral nutrition

Immune-enhancing EN is not recommended for routine use in critically ill patients in the ICU. Immune-enhancing EN is not associated with reduced infectious complications, LOS, reduced cost of medical care, days on mechanical ventilation or mortality in moderately to less severely ill ICU patients. Their use may be associated with increased mortality in severely ill ICU patients, although adequately powered trials evaluating this have not been conducted. For the trauma patient, it is not recommended to routinely use immune-enhancing EN, because its use is not associated with reduced mortality, reduced LOS, reduced infectious complications or fewer days on mechanical ventilation.

 

Rating: Fair

Imperative

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

Guideline/Step of Care Process with Nutrition Implications

Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injurya

American Society for Parenteral and Enteral Nutrition Critically Ill Patientb

 

 

(See guideline D4 for recommendations on gastric residual volumes, identifying high-risk patients, and reducing chances for aspiration.)

 

 

B1. If early EN is not feasible or available the first 7 days following admission to the ICU, no nutrition support therapy (i.e., standard therapy) should be provided. (Grade: C)

 

 

In the patient who was previously healthy prior to critical illness with no evidence of protein calorie malnutrition, use of PN should be reserved and initiated only after the first 7 days of hospitalization (when EN is not available). (Grade: E)

 

 

B2. If there is evidence of protein-calorie malnutrition on admission and EN is not feasible, it is appropriate to initiate PN as soon as possible following admission and adequate resuscitation. (Grade: C)

 

 

B3. If a patient is expected to undergo major upper GI surgery and EN is not feasible, PN should be provided under very specific conditions: If the patient is malnourished, PN should be initiated 5–7 days preoperatively and continued into the postoperative period. (Grade: B)

 

 

PN should not be initiated in the immediate postoperative period but should be delayed for 5–7 days (should EN continue not to be feasible). (Grade: B)

 

 

PN therapy provided for a duration of < 5–7 days would be expected to have no outcome effect and may result in increased risk to the patient. Thus, PN should be initiated only if the duration of therapy is anticipated to be ≥ 7 days. (Grade: B)

 

 

C2. Efforts to provide > 50–65% of goal calories should be made in order to achieve the clinical benefit of EN over the first week of hospitalization. (Grade: C)

 

 

C3. If unable to meet energy requirements (100% of target goal calories) after 7–10 days by the enteral route alone, consider initiating supplemental PN. (Grade: E) Initiating supplemental PN prior to this 10-day period in the patient already receiving EN does not improve outcome and may be detrimental to the patient. (Grade: C)

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

American Dietetic Association—Critical Illnessc

American Association of Neuroscience Nurses—Nursing Management of Adults with Severe TBId

CI: Feeding tube placement

EN administered into the stomach is acceptable for most critically ill patients. Consider placing feeding tube in the small bowel when patient is in supine position or under heavy sedation. If your institution’s policy is to measure gastric residual volume (GRV), then consider small bowel tube feeding placement in patients who have more than 250 ml GRV or formula reflux in two consecutive measures. Small bowel tube placement is associated with reduced GRV. Adequately powered studies have not been conducted to evaluate the impact of GRV on aspiration pneumonia. There may be specific disease states or conditions that may warrant small bowel tube placement (e.g., fistulas, pancreatitis, gastroparesis); however, they were not evaluated at this phase of the analysis.

Providing continuous intragastric feeding may improve tolerance (Level 3)

Continuous feeding was better tolerated and achieved 75% of nutritional goals faster than bolus feeding in patients admitted to a neurosurgical ICU (20% of whom had sustained a severe TBI). Feeding via percutaneous endoscopic gastrostomy in patients with moderate-to-severe TBI was well tolerated without complication in 97% of patients.

 

Rating: Fair

Conditional

 

 

Prokinetic agents have shown no effect on feeding tolerance (Level 2)

A prospective randomized double-blind study of patients with severe TBI that compared metoclopramide with normal saline found no difference in feeding intolerance or complication rates between the groups. Prokinetic agents demonstrated no improvement in feeding tolerance in patients in barbiturate-induced comas for refractory intracranial hypertension. The amount of time it took to achieve nutritional goals was not reduced with the use of prokinetic agents in a neurosurgical ICU in which 20% of patients had severe TBI.

 

 

Administering intensive insulin therapy for serum glucose greater than 110 mg/dl improves outcomes (Level 2)

Glucose levels exceeding 170 mg/dl during the first 5 days post-severe TBI correlate with prolonged hospital length of stay and increased mortality. Administering intensive insulin therapy for elevated serum glucose can improve outcomes. A glucose level higher than 200 mg/dl that goes untreated during the first 24 hours post-severe TBI has been associated with worse outcomes and is related to increased ICP and impaired pupillary reaction.

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

Guideline/Step of Care Process with Nutrition Implications

Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injurya

American Society for Parenteral and Enteral Nutrition Critically Ill Patientb

 

 

C4. Ongoing assessment of adequacy of protein provision should be performed. The use of additional modular protein supplements is a common practice, as standard enteral formulations tend to have a high nonprotein calorie:nitrogen ratio. In patients with body mass index (BMI) < 30, protein requirements should be in the range of 1.2–2.0 g/kg actual body weight per day, and may likely be even higher in burn or multi-trauma patients. (Grade: E)

 

 

C5. In the critically ill obese patient, permissive underfeeding or hypocaloric feeding with EN is recommended. For all classes of obesity where BMI is > 30, the goal of the EN regimen should not exceed 60–70% of target energy requirements or 11–14 kcal/kg actual body weight per day (or 22–25 kcal/kg ideal body weight per day). Protein should be provided in a range ≥ 2.0 g/kg ideal body weight per day for Class I and II patients (BMI 30–40), ≥ 2.5 g/kg ideal body weight per day for Class III (BMI ≥ 40). Determining energy requirements is discussed in guideline C1. (Grade: D)

 

 

D1. In the ICU setting, evidence of bowel motility (resolution of clinical ileus) is not required in order to initiate EN in the ICU. (Grade: E)

 

 

D3. Use of enteral feeding protocols increases the overall percentage of goal calories provided and should be implemented. (Grade: C)

 

 

E1. Immune-modulating enteral formulations (supplemented with agents such as arginine, glutamine, nucleic acid, n-3 fatty acids, and antioxidants) should be used for the appropriate patient population (major elective surgery, trauma, burns, head and neck cancer, and critically ill patients on mechanical ventilation), with caution in patients with severe sepsis. (For surgical ICU patients, Grade: A) (For medical ICU patients, Grade: B) ICU patients not meeting criteria for immune-modulating formulations should receive standard enteral formulations. (Grade: B)

 

 

E2. Patients with Acute respiratory distress syndrome (ARDS) and severe acute lung injury (ALI) should be placed on an enteral formulation characterized by an anti-inflammatory lipid profile (i.e., n-3 fish oils, borage oil) and antioxidants. (Grade: A)

 

 

E3. To receive optimal therapeutic benefit from the immune-modulating formulations, at least 50–65% of goal energy requirements should be delivered. (Grade: C)

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

American Dietetic Association—Critical Illnessc

American Association of Neuroscience Nurses—Nursing Management of Adults with Severe TBId

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

Guideline/Step of Care Process with Nutrition Implications

Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injurya

American Society for Parenteral and Enteral Nutrition Critically Ill Patientb

 

 

E4. If there is evidence of diarrhea, soluble-fiber-containing or small peptide formulations may be utilized. (Grade: E)

 

 

F1. Administration of probiotic agents has been shown to improve outcome (most consistently by decreasing infection) in specific critically ill patient populations involving transplantation, major abdominal surgery, and severe trauma. (Grade: C)

 

 

No recommendation can currently be made for use of probiotics in the general ICU population because of a lack of consistent outcome effect. It appears that each species may have different effects and variable impact on patient outcome, making it difficult to make broad categorical recommendations. Similarly, no recommendation can currently be made for use of probiotics in patients with severe acute necrotizing pancreatitis, based on the disparity of evidence in the literature and the heterogeneity of the bacterial strains utilized.

Monitoring and evaluations of nutrition-related indicators

 

D2. Patients should be monitored for tolerance of EN (determined by patient complaints of pain and/or distention, physical exam, passage of flatus and stool, abdominal radiographs). (Grade: E)

 

Inappropriate cessation of EN should be avoided. (Grade: E) Holding EN for gastric residual volumes < 500 mL in the absence of other signs of intolerance should be avoided. (Grade: B)

 

The time period that a patient is made nil per os (NPO; no food or drink thourhg the mouth) prior to, during, and immediately following the time of diagnostic tests or procedures should be minimized to prevent inadequate delivery of nutrients and prolonged periods of ileus. Ileus may be propagated by NPO status. (Grade: C)

 

D4. Patients placed on EN should be assessed for risk of aspiration. (Grade: E) Steps to reduce risk of aspiration should be employed. (Grade: E) The following measures have been shown to reduce risk of aspiration: In all intubated ICU patients receiving EN, the head of the bed should be elevated 30–45 degrees. (Grade: C) For high-risk patients or those shown to be intolerant to gastric feeding, delivery of EN should be switched to continuous infusion. (Grade: D)

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

American Dietetic Association—Critical Illnessc

American Association of Neuroscience Nurses—Nursing Management of Adults with Severe TBId

CI: Blue dye use and critically ill patients

Blue dye should not be added to EN for detection of aspiration. The risk of using blue dye outweighs any perceived benefit. The presence of blue dye in tracheal secretions is not a sensitive indicator for aspiration.

 

 

Rating: Strong

Imperative

 

CI: Monitoring patient position

Evaluating patient position should be part of an EN monitoring plan. To decrease the incidence of aspiration pneumonia and reflux of gastric contents into the esophagus and pharynx, critically ill patients should be placed in a 45-degree head of bed elevation, if not contraindicated.

 

 

Rating: Strong

Imperative

 

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

Guideline/Step of Care Process with Nutrition Implications

Brain Trauma Foundation (BTF) Guidelines for the Management of Severe Traumatic Brain Injurya

American Society for Parenteral and Enteral Nutrition Critically Ill Patientb

 

 

Agents to promote motility such as prokinetic drugs (metoclopramide and erythromycin) or narcotic antagonists (naloxone and alvimopan) should be initiated where clinically feasible. (Grade: C) Diverting the level of feeding by post-pyloric tube placement should be considered. (Grade: C) Use of chlorhexidine mouthwash twice a day should be considered to reduce risk of ventilator-associated pneumonia. (Grade: C)

 

 

D5. Blue food coloring and glucose oxidase strips, as surrogate markers for aspiration, should not be used in the critical care setting. (Grade: E)

 

 

D6. Development of diarrhea associated with enteral tube feedings warrants further evaluation for etiology. (Grade: E)

 

 

F2. A combination of antioxidant vitamins and trace minerals (specifically including selenium) should be provided to all critically ill patients receiving specialized nutrition therapy. (Grade: B)

 

 

F3. The addition of enteral glutamine to an EN regimen (not already containing supplemental glutamine) should be considered in burn, trauma, and mixed ICU patients. (Grade: B)

 

 

F4. Soluble fiber may be beneficial for the fully resuscitated, hemodynamically stable critically ill patient receiving EN who develops diarrhea. Insoluble fiber should be avoided in all critically ill patients. Both soluble and insoluble fiber should be avoided in patients at high risk for bowel ischemia or severe dysmotility. (Grade: C)

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

American Dietetic Association—Critical Illnessc

American Association of Neuroscience Nurses—Nursing Management of Adults with Severe TBId

CI: Monitoring gastric residual volume

Evaluating GRV in critically ill patients is an optional part of a monitoring plan to assess tolerance of EN. Enteral nutrition should be held when a GRV greater than or equal to 250 ml is documented on two or more consecutive occasions. Holding EN when GRV is less than 250 ml is associated with delivery of less EN. Gastric residual volume may not be a useful tool to assess the risk of aspiration pneumonia. Adequately powered studies have not been conducted to evaluate the impact of GRV on aspiration pneumonia.

 

 

Rating: Consensus

Imperative

 

CI: Monitoring and promotility agents

If the patient exhibits a history of gastroparesis or repeated high GRVs, then consider the use of a promotility agent in critically ill ICU patients, if there are no contraindications. The use of a promotility agent (e.g., metoclopramide) has been associated with increased GI transit, improved feeding tolerance, improved EN delivery, and possibly reduced risk of aspiration.

 

 

Rating: Strong

Conditional

 

CI: Monitoring delivery of energy

Monitoring plan of critically ill patients must include a determination of daily actual EN intake. Enteral nutrition should be initiated within 48 hours of injury or admission and average intake actually delivered within the first week should be at least 60–70% of total estimated energy requirements as determined in the assessment. Provision of EN within this time frame and at this level may be associated with a decreased LOS, days on the mechanical ventilation, and infectious complications.

 

 

Rating: Fair

Imperative

 

Glucose Monitoring Recommendation was removed and is under revision (Sep 2009)

 

CI: Thermic effect of continuous feeding on RMR

If a critically ill patient is continuously receiving any energy source (e.g., intravenous fluids, EN or PN), the rate and concentration should remain unchanged during the 24-hour period before and during RMR measure. After 24-hour equilibration, the impact of the thermal effect of food (TEF) on RMR is constant and indirect calorimetry measurements can proceed.

 

 

Rating: Fair

Conditional

 

CI: Thermic effect of intermittent feeding on RMR

If a critically ill patient receives intermittent EN above 400 kcal per feeding, then hold feedings for a minimum of five hours before measuring RMR. When a five-hour fast is not clinically feasible or when a small feeding (< 400 kcal) is given, a four-hour fast is allowed. Measuring RMR during the time of the TEF will produce inaccurately high values.

 

 

Rating: Weak

Conditional

 

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

Guideline/Step of Care Process with Nutrition Implications

Brain Trauma Foundation (BTF)

Guidelines for the Management of Severe Traumatic Brain Injurya

American Society for Parenteral and Enteral Nutrition Critically Ill Patientb

 

 

G1. If EN is not available or feasible, the need for PN therapy should be evaluated (see guidelines B1, B2, B3, C3). (Grade: C) If the patient is deemed to be a candidate for PN, steps to maximize efficacy (regarding dose, content, monitoring, and choice of supplemental additives) should be used. (Grade: C)

 

 

G2. In all ICU patients receiving PN, mild permissive underfeeding should be considered at least initially. Once energy requirements are determined, 80% of these requirements should serve as the ultimate goal or dose of parenteral feeding. (Grade: C) Eventually, as the patient stabilizes, PN may be increased to meet energy requirements. (Grade: E) For obese patients (BMI ≥ 30), the dose of PN with regard to protein and caloric provision should follow the same recommendations given for EN in guideline C5. (Grade: D)

 

 

G3. In the first week of hospitalization in the ICU, when PN is required and EN is not feasible, patients should be given a parenteral formulation without soy-based lipids. (Grade: D)

 

 

G4. A protocol should be in place to promote moderately strict control of serum glucose when providing nutrition support therapy. (Grade: B) A range of 110–150 mg/dL may be most appropriate. (Grade: E)

 

 

G5. When PN is used in the critical care setting, consideration should be given to supplementation with parenteral glutamine. (Grade: C)

 

 

G6. In patients stabilized on PN, periodically repeated efforts should be made to initiate EN. As tolerance improves and the volume of EN calories delivered increases, the amount of PN calories supplied should be reduced. PN should not be terminated until ≥ 60% of target energy requirements are being delivered by the enteral route. (Grade: E)

 

 

H1. Specialty high-lipid low-carbohydrate formulations designed to manipulate the respiratory quotient and reduce CO2 production are not recommended for routine use in ICU patients with acute respiratory failure. (Grade: E) (This is not to be confused with guideline E2 for ARDS/ALI).

 

 

H2. Fluid-restricted calorically dense formulations should be considered for patients with acute respiratory failure. (Grade: E)

 

 

H3. Serum phosphate levels should be monitored closely and replaced appropriately when needed. (Grade: E)

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

American Dietetic Association—Critical Illnessc

American Association of Neuroscience Nurses—Nursing Management of Adults with Severe TBId

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

Guideline/Step of Care Process with Nutrition Implications

Brain Trauma Foundation (BTF)

Guidelines for the Management of Severe Traumatic Brain Injurya

American Society for Parenteral and Enteral Nutrition Critically Ill Patientb

 

 

(NOT including renal pancreatitis and end of life)

a Bratton et al., 2007.

b McClave et al., 2009.

c ADA, 2006.

d Mcilvoy and Meyer, 2008.

TABLE B-2 Summary Table for Nutrition Content of Existing EBGs for Non-ICU Acute TBI

Guideline/Care Process

Guidelines for the Field Management of Combat-Related Head Traumaa

Mild TBI-Acute Nondeployed Care; Mild TBI Sub-Acute

Interdisciplinary team (referrals to PT, OT, Speech & Language pathology, pharmacy, audiology/vestibular and optometry)

VA Management of Concussion/Mild Traumatic Brain Injuryb

(Adults, nonacute, not management of moderate or severe TBI)

Nutrition-related assessment information

Neurobehavioral Symptom Inventory (includes nausea, change in appetite, taste or smell)

Patient Health Questionnaire (includes changes in appetite)

Sub-Acute Cognitions (normalize nutrition)

BMI > 30 (Refer for Sleep Study)

Nausea, vomiting

Change in appetite

Change in taste or smell

Specific nutrition interventions

Novel therapy (nutritional supplements)

Limit caffeine and alcohol.

Minimize caffeine and avoid herbal diet supplements such as “energy” products as some contain agents that cross-react with psychiatric mediation and lead to a hypertensive crisis.

Novel therapy (hyperbaric oxygen, nutritional supplements) modalities in the management of concussion/mTBI are being explored in the field as potential treatment approaches. It is the recommendation of the Working Group that interventions that lack sufficient empirical support should occur only under the auspices of an IRB-reviewed protocol.

Monitoring and evaluations of nutrition-related indicators

 

 

aKnuth, 2005.

bDepartment of Veterans Affairs and Department of Defense (VA/DoD), 2009.

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

American Dietetic Association—Critical Illnessc

American Association of Neuroscience Nurses—Nursing Management of Adults with Severe TBId

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

TABLE B-3 Questions to Guide Future Research Searches to Support Future Evidence-Based Guidelines for Nutrition in TBI Patientsa,b,c

Population

Intervention (Assessment factor of interest)

Comparator (Alternative assessment factor)

Outcome

Assessment questions

Acute TBI patients

Selected biomarkers or constellation of biomarkers (e.g., Ca2+, ROS, protein carbonyls, lipid peroxidase, S-100B, neuron specific enolase, glial fibrillary acidic protein, myelin basic protein, phosphorylated neurofilament H, ubiquitin C-Terminal hydrolase, a-II spectrin, microtubule-binding protein Tau, F2-isoprostane, and 4-hydroxynonenol)

Other biomarkers and neuroimaging studies

Sensitive and specific predictor of the level of brain damage and oxidative stress (vs. other types of injuries or conditions)

Or

Sensitive and specific predictor of mitochondrial function post injury

TBI patients

Remeasurement of energy needs at specific intervals

Monitoring weight and nutrition intake

Maintaining optimal body composition

Acute TBI patients being considered for progesterone treatment for TBI

Serum 25-hydroxyvitamin D

Vitamin D intake

Vitamin D adequacy

Treatment/intervention questions

Acute TBI in ICU setting

Parenteral nutrition

Enteral nutrition

Tight glucose control

Range of control with decreased risk of hypoglycemia and accounting for risks of hypoglycemia (limits to be defined)

Acute TBI in ICU setting

Adjustment of nutrition and medication to maintain “tight” glucose control (e.g., 80–110 mg/dl)

Adjustment of nutrition and medication to maintain “moderate” glucose control (less than 150 mg/dl)

Recovery parameters to severe TBI (e.g., intracranial pressure, increase the level of consciousness, duration of ICU stay or duration of intubation)

Acute TBI in ICU setting in first 24 hours to 7 days

Permissive underfeeding (50–80% of estimated energy needs using specified method to estimate energy needs)

Higher percentage of estimated energy needs (e.g., greater than 80%)

Recovery parameters (See above)

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

Population

Intervention (Assessment factor of interest)

Comparator (Alternative assessment factor)

Outcome

Acute TBI with severe reduction in mitochondrial function as shown by selected biomarker levels (NOTE: Only practical if assessment methods are able to identify patients with reduction in mitochondrial function—see related assessment question)

Alternative energy sources (e.g., ketones from a ketogenic diet)

Traditional sources of energy (carbohydrate, protein, fat)

Minimize depressed mitochondrial functioning using biomarkers from assessment (e.g., lactate production would indicate use of ketones)

Acute severe TBI injury

IV n-3 fatty acid as additional or sole source of fat (dose TBD)

Normal IV fat emulsion (fatty acid dose TBD)

Recovery factors for severe TBI or research parameters of resolvins, protectins, tumor necrosis factor, fatty acid profile

Mild TBI injury or repeated mild TBI injury

Postoperative supplemental n-3 fatty acid (dose TBD)

Normal or nonsupplemented diet n-3 fatty acid (dose TBD)

Resolvins, protectins, tumor necrosis factor

Mild TBI injury or repeated mild TBI injury (by time period, 14–30 days or 45–50 days for repeated injuries)

Eucaloric ketogenic diet (dose TBD)

Normal diet (TBD)

Reduce impact on mitochondrial function deficit with corresponding improvement in clinical symptoms (Note: Ideally have assessment methods to measure level of mitochondrial function versus relying on clinical symptoms)

Postacute phase severe TBI

Eucaloric ketogenic diet (dose TBD)

Normal diet (TBD)

Reduce impact on mitochondrial function deficit with corresponding improvement in clinical symptoms (Note: Ideally have assessment methods to measure level of mitochondrial function versus relying on clinical symptoms)

Postacute phase of either mild or severe TBI

Choline supplementation (dose above Daily Recommended Intake)

Normal dietary choline content (dose TBD)

Cognitive functioning indicator e.g., National Institute of Child Health and Human Development combined TBI outcome statistic as well as identify potential negative side effects

Postacute phase severe TBI (by gender)

Creatine supplementation (dose TBD)

Nonsupplemented diet (Baseline dose TBD)

Signs and symptoms of TBI, e.g., reduction in headaches, fatigue, and depression and improved cognitive function as well as identifying potential negative side effects

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

Population

Intervention (Assessment factor of interest)

Comparator (Alternative assessment factor)

Outcome

Postacute phase severe TBI

Preinjury creatine supplementation

Preinjury nonsupplemented diet

Signs and symptoms of TBI, e.g., reduction in headaches, fatigue, and depression and improved cognitive function as well as identifying potential negative side effects

Acute moderate to severe TBI

Zinc administration above DRI level (timing—e.g., hours postinjury, dose and duration—TBD)

Zinc at optimal levels (DRI)

Enhanced memory, reduction in depression, and anxiety symptoms as well as identifying potential negative side effects

Chronic TBI patient

Various counseling theories and strategies (e.g., memory books, motivational interviewing, problem-solving, self-monitoring)

Comparator counseling theories and strategies

Optimal dietary intake matching nutrient needs

Severe TBI with multiple trauma injuries, postacute phase

Branched-chain amino acids as % of total amino acid intake (IV or diet with varying amounts of leucine, isoleucine, and valine—doses TBD, duration < 1 week)

Normal amino acid formula or nonsupplemented diet (baseline dose TBD)

Disability Rating Scale Score, memory or cognitive functioning

TBI, chronic

Novel nutrition therapies sold as dietary supplements (e.g., combinations of resveratrol, curcumin, polyphenols, creatine and CDP-choline)

Nonsupplemented diet (baseline doses TBD)

Improved cognitive function (indicator TBD) as well as identifying potential negative side effects

Monitoring/evaluating questions

TBI patients (by mild, moderate, severe over specified time and event intervals)

Reassessment of energy needs (RMR)

Original RMR

Significant differences between original RMR and reassessed RMR

TBI patients

Brain-specific biomarkers for improvement in brain function

Other assessment biomarkers

Improved brain function

aTo aid those preparing future clinical practice guidelines for severe TBI, the questions have been formatted in the Population/Participant, Intervention, Comparator, Outcome (PICO) format. The questions are organized by the step in the care process to which the questions apply, i.e., assessment procedures, types of interventions to be selected, and the types of monitoring and evaluating parameters to be used.

bStrauss, S. E., W. S. Richardson, P. Glasziou, and R. B. Haynes. 2005. Evidence-based medicine: How to practice and teach EBM. Edinburgh: Churchill Livingstone.

cGuyatt, G., R. Drummond, M. O. Meade, and D. J. Cook, eds. 2008. Users’ guides to the medical literature: Amanual for evidence-based clinical practice, 2nd Edition. Chicago: American Medical Association.

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×

REFERENCES

ADA (American Dietetic Association). 2006. Critical illness evidence-based nutrition practice guideline. American Dietetic Association. http://www.adaevidencelibrary.com/topic.cfm?cat=2799 (accessed October 26, 2010).

Bratton, S. L., R. M. Chestnut, J. Ghajar, F. F. McConnell Hammond, O. A. Harris, R. Hartl, G. T. Manley, A. Nemecek, D. W. Newell, G. Rosenthal, J. Schouten, L. Shutter, S. D. Timmons, J. S. Ullman, W. Videtta, J. E. Wilberger, and D. W. Wright. 2007. Guidelines for the management of severe traumatic brain injury. XII. Nutrition. Journal of Neurotrauma 24 (Suppl. 1):S77–S82.

Knuth, T., P. B. Letarte, G. Ling, L. E. Moores, P. Rhee, D. Tauber, and A. Trask. 2005. Guidelines for the field management of combat-related head trauma. New York: Brain Trauma Foundation.

McClave, S. A., R. G. Martindale, V. W. Vanek, M. McCarthy, P. Roberts, B. Taylor, J. B. Ochoa, L. Napolitano, and G. Cresci. 2009. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition 33(3):277–316.

Mcilvoy, L., and K. Meyer. 2008. Nursing management of adults with severe traumatic brain injury. Glenview, IL: American Association of Neuroscience Nurses.

VA/DoD (Department of Veterans Affairs and Department of Defense). 2009. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury. http://www.healthquality.va.gov/mtbi/concussion_mtbi_full_1_0.pdf (accessed January 19, 2011).

Suggested Citation:"Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury." Institute of Medicine. 2011. Nutrition and Traumatic Brain Injury: Improving Acute and Subacute Health Outcomes in Military Personnel. Washington, DC: The National Academies Press. doi: 10.17226/13121.
×
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×
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×
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×
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×
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×
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×
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×
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Traumatic brain injury (TBI) accounts for up to one-third of combat-related injuries in Iraq and Afghanistan, according to some estimates. TBI is also a major problem among civilians, especially those who engage in certain sports. At the request of the Department of Defense, the IOM examined the potential role of nutrition in the treatment of and resilience against TBI.

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