Effect of early nutrition on deaths due to severe traumatic brain injury

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Object

Traumatic brain injury (TBI) remains a serious public health crisis requiring continuous improvement in pre-hospital and inhospital care. This condition results in a hypermetabolic state that increases systemic and cerebral energy requirements, but achieving adequate nutrition to meet this demand has not been a priority in reducing death due to TBI. The effect of timing and quantity of nutrition on death within the first 2 weeks of injury was analyzed in a large prospective database of adult patients with severe TBI in New York State.

Methods

The study is based on 797 patients with severe TBI (Glasgow Coma Scale [GCS] score < 9) treated at 22 trauma centers enrolled in a New York State quality improvement program between 2000 and 2006. The inhospital section of the prospectively collected database includes information on age, initial GCS score, weight and height, results of CT scanning, and daily parameters such as pupillary status, arterial hypotension, GCS score, and number of calories fed per day.

Results

Patients who were not fed within 5 and 7 days after TBI had a 2- and 4-fold increased likelihood of death, respectively. The amount of nutrition in the first 5 days was related to death; every 10-kcal/kg decrease in caloric intake was associated with a 30–40% increase in mortality rates. This held up even after controlling for factors known to affect mortality, including arterial hypotension, age, pupillary status, initial GCS score, and CT scan findings.

Conclusions

Nutrition is a significant predictor of death due to TBI. Together with prevention of arterial hypotension, hypoxia, and intracranial hypertension it is one of the few therapeutic interventions that can directly affect TBI outcome.

Abbreviations used in this paper: CPP = cerebral perfusion pressure; GCS = Glasgow Coma Scale; ICP = intracranial pressure; ICU = intensive care unit; TBI = traumatic brain injury.

Article Information

Address correspondence to: Roger Härtl, M.D., Department of Neurological Surgery, Weill Cornell Medical College, Starr Building, Room 651, 525 East 68th Street, Box 99, New York, New York 10021. email: roger@hartlmd.net.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Line graph showing the predicted mortality as a function of maximum nutrition level. Regression models were adjusted for age, hypotension status on Day 1, pupil status (normal or abnormal) on Day 1, initial GCS score, and CT scan findings. Solid lines represent the maximum amount of nutritional support, and dashed lines indicate the 95% confidence interval.

  • View in gallery

    Flow diagram showing the number of patients (N) in whom ICP monitoring was performed and the nutritional support they received.

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