What are the nutritional recommendations for patients with Traumatic Brain Injury (TBI)?

Nutritional Management in Traumatic Brain Injury

Early enteral nutrition should be initiated within 72 hours of TBI to reduce mortality and improve outcomes. 1, 2

Energy and Protein Requirements

Energy Needs

• Use indirect calorimetry (IC) whenever possible as the gold standard for determining energy requirements 2
• When IC is not available:
  • Target 1.4-1.5 times measured resting energy expenditure (REE) after acute phase 2
  • Minimum intake of 57 kcal/kg/day is required to achieve protein anabolic state 2
  • Each 10 kcal/kg reduction in caloric intake is associated with a 30-40% increase in mortality 3

Protein Requirements

• Target at least 1.5 g protein/kg/day to achieve a protein anabolic state 2
• For general trauma patients, provide 1.5-2.0 g/kg/day of protein 2
• Phased approach to protein delivery:
  • Early phase (ICU day 1-2): Low-dose protein (<0.8 g/kg/day)
  • As patient stabilizes: Increase to ≥1.2 g/kg/day 2

Timing and Route of Nutrition

Timing

• Initiate enteral nutrition within 72 hours of TBI admission 1, 2
• Aim to achieve full nutritional replacement by 7 days 2
• Patients not fed within 5-7 days after TBI have a 2-4 fold increased likelihood of death 3

Route

1. Enteral Nutrition (EN) is the preferred route 1

   • Use gastric access as standard initial approach 2
   • Consider post-pyloric feeding in case of persistent gastric retention 1
   • Small-bowel feeding may reduce pneumonia rates compared to nasogastric feeding 4

2. Parenteral Nutrition (PN)

   • Reserve for cases where EN is contraindicated or insufficient 1
   • Consider when there is intestinal discontinuity, prolonged ileus, or viable intestine <75 cm 2

Formula Selection

• Standard whole protein formula is appropriate for most patients 1
• Immune-modulating diets are not recommended for pediatric TBI patients 1
• Kitchen-made (blenderized) diets for tube feeding are not recommended due to risk of tube clogging and infection 1

Implementation Strategy

1. Initial Phase (First 24-72 hours)

   • Start enteral feeding within 24-72 hours 1
   • Begin with low flow rate (10-20 ml/h) 1
   • Target 70-80% of estimated requirements to avoid overfeeding 2

2. Progression Phase

   • Increase feeding rate carefully and individually due to limited intestinal tolerance 1
   • May take 5-7 days to reach target intake 1
   • Advance protein intake as patient stabilizes 2

3. Monitoring

   • Track delivered energy/protein and percentage of targets achieved 2
   • Monitor for refeeding syndrome, particularly hypophosphatemia 2
   • Monitor for insulin resistance and maintain blood glucose within target range 2
   • Evaluate micronutrient levels after ICU day 5-7, especially in patients on CRRT 2

Special Considerations

• Delayed Gastric Emptying: Consider prokinetics followed by post-pyloric feeding 1
• Prone Positioning: Enteral nutrition should not be delayed solely because of prone positioning 1
• Hyperglycemia: Control with insulin to improve lean body mass, bone mineral density, and wound healing 2
• Physical Activity: Implement rehabilitation as soon as possible to minimize muscle loss 2

Practical Challenges

• TBI patients experience complex physiologic derangements that may alter metabolic demand 5
• Contemporary neurocritical care practices may blunt the expected hypermetabolic state after TBI 5
• Dysphagia is common and requires monitoring to avoid aspiration 6

By implementing these evidence-based nutritional strategies, clinicians can significantly impact mortality, infection rates, and neurological outcomes in TBI patients.