The Initiation of Enteral and

Parenteral Feeding and Its Effect on

Morbidity and Mortality Rates After
Traumatic Brain Injury

Presented By: Jaclyn Kiernan

Sodexo Dietetic Intern, South Nassau Communities Hospital
Master of Science Candidate, University of Rhode Island
 Learning Objectives:
1. To understand the biochemistry processes of
the body following a TBI and be able to elaborate
on the need for increased Calories and protein.

2. To be able to respond appropriately to a patient

following a TBI and identify if EN, PN or EN + PN is
most appropriate.

3. To support the need for the development of

global parameters to determine the appropriate
timing and route of feedings.
Visualize This
 Traumatic Brain Injury
A traumatic brain injury (TBI) occurs when a bump,
blow or other head injury causes damage to the brain.1

A TBI can lead to psychological changes

The effects of a TBI often last a lifetime and cannot be

reversed

Common causes of TBI include stroke,

encephalopathy, falls, anoxic brain injury and brain
tumors.
 Biochemistry
Within 2-6 hours all of the bodys glycogen
stores are depleted

Priority of the body is then to protect the brain

Metabolic rate increases leading to an

increased kcal need and protein need.
Nutritional Needs:
Calories: 35-40
kcal/ kg Actual
Body Weight
Protein: 1.5-2.2 gm/
kg Actual Body
Weight
Enteral Feeding
Parenteral Nutrition
 Mortality & Morbidity
Rates
Morbidity rate is defined as the frequency with
which a disease appears in a population.2

Mortality rate is defined as the measure of the

number of deaths in a particular population,
scaled to the size of that population per unit of
time.2
 Need For the Study
No global parameters

No protocol regarding when feeding should be

initiated, what type of feeding should be
initiated, or what route of feeding is the most
optimal.

Clinicians are often left confused and unsure of

the proper steps.
 Nutrition in the Acute Care
Setting For TBI Patients
Both energy and protein deficits are
associated with worse outcomes.3

The American Association of Neurological

Surgeons currently recommends full nutrition
replacement by the seventh day.4

No current evidence that feeding by the

seventh day will improve the outcome.4
 Timing of the Feeds
After examining multiple studies that were focused on the timing of the
initiation of nutritional support the conclusion is inconclusive.

Some studies concluded that the timing of the feeds did not affect
clinical outcome.

One study concluded that patients who were not fed within 5-7 days had
an increased likelihood of death.

One study also noted that the nutrition provided within the first five days
of nutrition support was directly related to mortality. For every 10
kcal/kg decease there was a 30-40% increase in mortality rate.

A meta analysis completed by Wang et. al examined 16 studies focused

on TBI and concluded that benefits to early nutrition support include
reduced mortality rates, improving functional outcome and decreasing
complications.
 Route of the Feed
Meirelles & Aguilar Nascimento examined 12
participants receiving EN and 10 participants receiving
PN and concluded that the route of the feeding did
not influence early inflammation response or clinical
outcome.9
Fan et. al examined 120 participants and divided them
into three separate groups- EN, PN and EN + PN. The
PN group experienced a decrease in serum protein,
albumin, prealbumin and hemoglobin. The EN group
experienced a smaller decrease in serum protein
albumin, prealbumin and hemoglobin while the EN +
PN group experienced an increase in serum protein,
albumin, prealbumin and hemoglobin.10
 Route of the Feed
(contd)
Mazaherpur et al. examined 60 patients. The 60
patients were separated into three groups- EN, PN
and EN + PN. While none of the groups met kcal
and protein needs, the EN + PN group came the
closest to meeting goals. This study concluded
that neither EN or PN alone can meet nutritional
goals but EN + PN should be preferred.11
A meta analysis by Chapple et al. examined 1045
patients amongst 31 ICUs. This study concluded
that patients with nutritional deficits have
increased mortality risks.12
 Limitations of Previous
Research
Variety of TBIs examined

Variety of Glasgow Coma Scores

Patients nutritional status prior to the TBI was

not known
Case Study:
 Case Study- JS
17 yo male s/p MVA
Admitting Diagnosis: intraventricular hemorrhage
Past Medical Hx: None
Past Surgical Hx: Unknown
Height: 69 inches
Admitting Weight: 168 lbs/ 76.4 kg
IBW= 160 lbs +/- 10%
 Case Study (contd)
December 13, 2016

Diet Order: Jevity 1.2 @ 65 mL/ hr + 3 packets Prosource q 8

hours.
Jevity 1.2 @ 65 mL/hr provides ~1300 mL, 1560 kcal, 72 gm protein
3 packets Prosource q 8 hours provides an additional 540 kcal, 135 gm
protein
Jevity 1.2 @ 65 mL/ hr + 3 packets Prosource q 8 hours provides a
total of ~2100 kcal, 207 gm protein

Caloric Needs= ~2400 kcal/ day (Based on IJEE) using 76.4 kg BW

Protein Needs = ~153 gm protein (Based on 2gm/kg BW)

 Case Study- JS (contd)
February 24, 2017

Current weight: 130 lbs/ 59 kg

Diet Order: Vital 1.5 @ 65 mL/ hr + 1 packet Prosource q 12 hours.

Vital 1.5 @ 65 mL/ hr x 20 hours provides 1300 mL, 1950 kcal, 88 gm protein.
1 packet Prosource q 12 hours provides and additional 120 kcal, 30 gm protein

Caloric Needs= ~2360-2660 kcal/ day (Based on 40-45 kcal/ kg BW)

Protein Needs= ~118-148 gm protein/ day (Based on 2-2.5 gm/ kg BW)

Fluid Needs= ~2950-3540 mL/ day (Based on 50-60 mL/ kg BW)

 Case Study- JS- Weight
Trends
Date: Weight:
December 12, 2016 168 lbs/76.4 kg
January 12, 2017 144 lbs/ 65 kg
January 24, 2017 137.12 lbs/ 62 kg
January 31, 2017 145 lbs/ 66 kg
February 7, 2017 134.5 lbs/ 61 kg
February 15, 2017 130.7 lbs/ 59 kg
February 19, 2017 130 lbs/ 59 kg
February 21, 2017 (likely inaccurate) 117.06 lbs/ 53 kg
 Prealbumin:
Marker of nutritional status
Used to detect protein-calorie malnutrition
Causes of high prealbumin: renal failure, Hodgkins
disease
Causes of low prealbumin: acute catabolic states,
hepatic disease, stress, infection, surgery,
malnutrition, low protein intake
WNL= 18-39 mg/dL; <10mg/dL represents severe
malnutrition
 Case Study- JS-
Prealbumin
Date: Lab Value:
December 19, 2016 5mg/dL
December 26, 2016 14 mg/dL
January 5, 2017 30 mg/ dL
January 13, 2017 18 mg/dL
January 27, 2017 23 mg/dL
February 12, 2017 19 mg/ dL
 Albumin:
Produced by the liver
Most prevalent protein in the blood

Causes of high albumin: dehydration

Causes of low albumin: edema, hepatic disease,
malabsorption, diarrhea, burns, ESRD,
malnutrition, low protein intake, stress,
overhydration, cancer

WNL= 3.5-5.0 gm/dL

 Case Study- JS- Albumin:
Date: Lab Value:
December 12, 2016 4.4 gm/dL
December 19, 2016 3.1 gm/dL
December 26, 2016 3.8 gm/ dL
January 1, 2017 3.9 gm/dL
January 7, 2017 3.5 gm/dL
January 10, 2017 2.9 gm/dL
January 18, 2017 4.3 gm/ dL
January 25, 2017 4.1 gm/dL
February 9, 2017 3.0 gm/dL
February 14, 2017 3.3 gm/dL
February 18, 2017 3.5 gm/dL
February 23, 2017 3.7 gm/ dL
 Clinical Timeline of
Procedures:
Patient Admitted December 12, 2016

Enteral Feeding Initiated: December 13, 2016- started on Jevity 1.2

on Day 2 and switched to Vital 1.5 on Day 5

During time at SNCH patient experienced Right forehead

subcutaneous hematoma, left sided occipital and supratentorial
hemorrhage, left pneumothorax, respiratory failure requiring
intubation, elevated LFTs.

Goal rate of Sodium was 150 mEq/L to prevent swelling

Patient was kept NPO on 1/6, 1/9, 1/10, 1/11

Palliative Care was consulted multiple times

 Case Study- JS (contd)
JS was discharged in early March 2017.

The severe weight loss should be noted.

Prealbumin and Albumin both fluctuated

JS only received EN and the EN was initiated

early.
 Future Research
Current research demonstrates meeting kcal and
protein needs is crucial for a decreased mortality rate

Currently uncertain whether PN or EN should be used

Future research should focus on using both EN and PN

together
 References:
Centers For Disease Control and Prevention. Injury prevention & control: traumatic brain injury & concussion. CDC
website. https://www.cdc.gov/traumaticbraininjury/get_the_facts.html. Published September 20, 2016. Accessed
January 19, 2017.

Oregon Health and Science University. Caloric intake following traumatic brain injury: the influence of food consistency.
http://digitalcommons.ohsu.edu/cgi/viewcontent.cgi?article=1701&context=etd&sei-
redir=1&referer=http%3A%2F%2Fwww.bing.com%2Fsearch%3Fq%3Dcalorie%2520needs%2520traumatic%2520brian%2520inj
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2calorie%20needs%20traumatic%20brian%20injury%22Published April 1, 2007. Accessed January 19, 2017.

ASPEN Guidelines. What is nutrition support therapy? ASPEN Website.

http://www.nutritioncare.org/About_Clinical_Nutrition/What_is_Nutrition_Support_Therapy/. Published 2016.
Accessed January 19, 2017.

Montalcini, T., Moraca, M., Ferro, Y., Romeo, S., Serra, S., Rasso, MG., Rossi, F., Sannita, W., Dolce, G., Pujia, A.
Nutritional parameters predicting pressure ulcers and short term mortality in patients with minimal conscious state as a
result of traumatic and non-traumatic acquired brain injury. J transl med. 2015; 13:305

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http://calder.med.miami.edu/pointis/tbiprov/NUTRITION/acute2.html. Published 1998. Accessed January 20, 2017.
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Horn, S., Kinikini, M., Moore, L., Hammond, F., Brandstater, M., Smout R. & Barrett, R.
Enteral nutrition for TBI patients in the rehabilitation setting: associations with patient
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Medical Dictionary. Medical Dictionary Website. http://medical-

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Questions?