Clinical malnutrition in severe traumatic brain injury: Factors associated and outcome at 6 months

 

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Abstract

Traumatic brain injury increases the metabolic response of body, and therefore nutritional demands. This study was undertaken to evaluate various clinical features of malnutrition in TBI and their influence on neurological outcome. Eighty eight adult patients within 24 hours of TBI admitted with GCS 4 to 8 without serious systemic disorder were enrolled for the study. They were monitored serially for various clinical features of malnutrition till 3 weeks and outcome assessed at 6 months. Every week there was a significant increase in number of patients with various clinical features of malnutrition. Pedal edema was the most frequent sign present in 70% of patients at three weeks, followed by skeletal prominence (19%) and cheilosis (12%). Clinical malnutrition showed significant association with poorer GCS (p=0.03), admission hypoproteinemia (p=0.03), and delayed full enteral feeding (p< 0.001). Unfavorable outcome at 6 months was noted in 30 out of 37 patients who had clinical malnutrition as compared to 3 out of 15 patients who had no clinical features of malnutrition (odds ratio 17.2, p< 0.001). In multivariate analysis, clinical malnutrition was significantly associated with unfavorable outcome independent of GCS (p=0.002). Analysis of individual clinical markers revealed pedal edema as the only single clinical marker with significant influence on unfavorable outcome at 6 months (p=0.01). Clinical malnutrition developed more among patients with poorer GCS, admission hypoproteinemia, delayed full enteral feeding, and was associated with unfavorable outcome at 6 months. Among the various clinical markers, only pedal edema showed independent association with unfavorable outcome.

• References

• 1 Ghajar J. Traumatic brain injury. Lancet 356 2000; 923-929
  CrossrefPubMedGoogle Scholar
• 2 Gururaj G. Epidemiology of traumatic brain injuries: Indian scenario. Neurol Res 24 2002; 24-28
  CrossrefPubMedGoogle Scholar
• 3 Clifton GL, Robertson CS, Grossman RG. et al The metabolic response to severe head injury. J Neurosurg 60 1984; 687-696
  CrossrefPubMedGoogle Scholar
• 4 Deutschman CS, Konstantinides FN, Raup S. et al Physiological & metabolic response to isolated closed head injury. Part 1: Basal metabolic state: Correlation of metabolic and physiological parameters with fasting and stressed controls. J Neurosurg 64 1986; 89-98
  CrossrefPubMedGoogle Scholar
• 5 Young B, Ott L, Norton J. Metabolic & nutritional sequelae in the non- steroid treated head injury patient. Neurosurgery 17 1985; 784-791
  CrossrefPubMedGoogle Scholar
• 6 Teasdale G, Jennett B. Assessment of coma and impaired consciousness- a practical scale. Lancet 02 1974; 81-84
  PubMedGoogle Scholar
• 7 McPherson RA. Specific proteins. In: Henry JB. ed. Clinical diagnosis and management by laboratory methods. 20th. ed. 2001. WB Saunders; Philadelphia: 249-263
  Google Scholar
• 8 Christakis G. How to make a nutritional diagnosis without really trying. J Flor Med Assoc 66 1979; 349-356
  PubMedGoogle Scholar
• 9 Hopkins B. Assessment of nutritional status. In: Gottschlich MM, Matarese LE, Shronts EP. eds. Nutrition Support Dietetics Core Curriculum. 2nd . ed. 1993. Silver Springs: American Society for Parenteral and Enteral Nutrition; 15-66
  Google Scholar
• 10 Mitchell MK. Nutrition across the life span. 2nd . ed. 2003. WB Saunders; Philadelphia: 44-65
  Google Scholar
• 11 Jennett B, Bond M. Assessment of outcome after severe brain damage: a practical scale. Lancet 01 1975; 480-484
  PubMedGoogle Scholar
• 12 Gadisseux P, Ward JD, Young HF. et al Nutrition & neurosurgical patient. J Neurosurg 60 1984; 219-232
  CrossrefPubMedGoogle Scholar
• 13 Rosner MJ, Newsome HH, Becker DP. Mechanical brain injury: the sympathoadrenal response. J Neurosurg 61 1984; 76-86
  CrossrefPubMedGoogle Scholar
• 14 Phillips R, Ott L, Young B. et al Nutritional support and measured energy expenditure of the child and adolescent with head injury. J Neurosurg 67 1987; 846-851
  CrossrefPubMedGoogle Scholar
• 15 Robertson CS, Clifton GL, Grossman RJ. et al Alteration in cerebral availability of metabolic substrates after severe head injury. J Trauma 28 1988; 1523-1531
  CrossrefPubMedGoogle Scholar
• 16 McClain CJ, Hennig B, Ott L. et al Mechanisms and implications of hypoalbuminemia in head injured patients. J Neurosurg 69 1988; 386-392
  CrossrefPubMedGoogle Scholar
• 17 Rapp RP, Young B, Twyman D. et al The favorable effect of early parenteral feeding on survival in severe head injured patients. J Neurosurg 58 1983; 906-912
  CrossrefPubMedGoogle Scholar
• 18 Young B, Ott L, Twyman D. et al The effect of nutritional support on outcome from severe head injury. J Neurosurg 67 1987; 668-676
  CrossrefPubMedGoogle Scholar
• 19 Yanagawa T, Bunn F, Roberts I. et al Nutritional support for head injured patients. Cochrane Database Syst Rev 03 2002; CD001530
  PubMedGoogle Scholar
• 20 Wilson RF, Dente C, Tyburski JG. The nutritional management of patients with head injuries. Neurol Res 23 2001; 121-128
  CrossrefPubMedGoogle Scholar