Nutrition and Traumatic Brain Injury Improving Acute and Subacute Health Outcomes in Military Personnel (2011) / Chapter Skim
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Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury
Appendix B: Evidence-Based Guidelines for Traumatic Brain Injury
Pages 263-285
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B Evidence-Based Guidelines for Traumatic Brain Injury 263
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Guideline/ Step of Care Process with Brain Trauma Foundation (BTF) Nutrition American Society for Parenteral and Enteral Nutrition Guidelines for the Management of Severe Traumatic Brain Injurya Critically Ill Patientb Implications Nutrition- A1.
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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%)
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266 NUTRITION AND TRAUMATIC BRAIN INJURY TABLE B-1 Continued Guideline/ Step of Care Process with Brain Trauma Foundation (BTF) Nutrition American Society for Parenteral and Enteral Nutrition Guidelines for the Management of Severe Traumatic Brain Injurya Critically Ill Patientb Implications
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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.
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EN is the preferred route of feeding over nitrogen to reduce weight by 15% parenteral nutrition (PN) for the critically ill patient per week; 100 to 140% replacement who requires nutrition support therapy.
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Immune-enhancing EN is not recommended for routine use in critically A study of the effect of malnutrition ill patients in the ICU. Immune-enhancing EN is not associated with on rehabilitation length of stay found reduced infectious complications, LOS, reduced cost of medical care, that patients with malnutrition had days on mechanical ventilation or mortality in moderately to less lengths of stay that were 28 days severely ill ICU patients.
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C3. If unable to meet energy requirements (100% of target goal calories)
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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)
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ICU patients not meeting criteria for immune-modulating formulations should receive standard enteral formulations. (Grade: B)
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273 APPENDIX B American Association of Neuroscience Nurses -- Nursing Management of American Dietetic Association -- Critical Illnessc Adults with Severe TBId continued
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Holding EN for gastric residual volumes < 500 mL in the absence of other signs of intolerance should be avoided. (Grade: B)
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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 continued
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should be provided to all critically ill patients receiving specialized nutrition therapy. (Grade: B)
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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.
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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.
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279 APPENDIX B American Association of Neuroscience Nurses -- Nursing Management of American Dietetic Association -- Critical Illnessc Adults with Severe TBId continued
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TABLE B-2 Summary Table for Nutrition Content of Existing EBGs for Non-ICU Acute TBI Guidelines for the Field Management of VA Management of Concussion/Mild Guideline/Care Combat-Related Head Traumaa Traumatic Brain Injuryb Process Mild TBI-Acute Nondeployed Care; Mild (Adults, nonacute, not management of TBI Sub-Acute moderate or severe TBI) Interdisciplinary team (referrals to PT, OT, Speech & Language pathology, pharmacy, audiology/vestibular and optometry)
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281 APPENDIX B American Association of Neuroscience Nurses -- Nursing Management of American Dietetic Association -- Critical Illnessc Adults with Severe TBId
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lipid peroxidase, S-100B, Or neuron specific enolase, glial fibrillary acidic Sensitive and specific predictor protein, myelin basic of mitochondrial function post protein, phosphorylated injury neurofilament H, ubiquitin C-Terminal hydrolase, a-II spectrin, microtubule binding protein Tau, F2-isoprostane, and 4-hydroxynonenol) TBI patients Remeasurement of Monitoring weight and Maintaining optimal body energy needs at specific nutrition intake composition intervals Acute TBI patients Serum Vitamin D intake Vitamin D adequacy being considered for 25-hydroxyvitamin D progesterone treatment for TBI 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)
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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 Choline supplementation Normal dietary choline Cognitive functioning mild or severe TBI (dose above Daily content (dose TBD)
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Outcome Postacute phase severe Preinjury creatine Preinjury Signs and symptoms of TBI, TBI supplementation nonsupplemented diet e.g., reduction in headaches, fatigue, and depression and improved cognitive function as well as identifying potential negative side effects Acute moderate to Zinc administration Zinc at optimal levels Enhanced memory, reduction severe TBI above DRI level (DRI) in depression, and anxiety (timing -- e.g., hours symptoms as well as postinjury, dose and identifying potential negative duration -- TBD)
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2008. Nursing management of adults with severe traumatic brain injury.
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