The metabolic response to severe head injury

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✓ Caloric expenditure and nitrogen balance were measured in 14 steroid-treated comatose head-injured patients acutely and up to 28 days after injury. During this period patients were fed with a continuous enteral infusion of a formula containing 2 Kcal/cc and 10 gm nitrogen/liter. Indirect calorimetry was carried out for 102 patient-days. The mean resting metabolic expenditure (RME) for nonsedated nonparalyzed patients was 138% ± 37% of that expected for an uninjured resting person of equivalent age, sex, and body surface area. Nitrogen excretion was measured for 135 patient-days. The mean excretion was 20.2 ± 6.4 gm/day. The mean protein caloric contribution was 23.9% ± 6.7% and was greater than 25% for six patients, compared to normal values of 10% to 15%. Despite hyperalimentation, positive nitrogen balance for any 3-day period was achieved in only seven patients, and required replacement of 161% to 240% of RME with enterally administered formula. Head-injured patients had a metabolic response similar to that reported for patients with burns of 20% to 40% of the body surface.

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Address reprint requests to: Guy L. Clifton, M.D., Department of Neurosurgery, Baylor College of Medicine, 6501 Fannin, Suite A404, Houston, Texas 77030.

© AANS, except where prohibited by US copyright law.

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    An example of metabolic data for one patient. Daily values for resting metabolic expenditure (RME), caloric intake, nitrogen excretion, nitrogen balance, and weight of a 30-year-old man with a Glasgow Coma Scale score of 7 during the first 2 weeks after injury.

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    The mean values of resting metabolic expenditure (RME) and nitrogen balance for 3-day periods in the first 9 days after injury. Data for 3-day periods (Days 1–3, 4–6, 7–9) were averaged and the means and standard deviations (vertical bars) are shown. Data from 14 patients are summarized on Days 1–3, for 11 patients on Days 4–6, and eight patients on Days 7–9. The means and standard deviations are presented in Table 2.

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    Metabolic expenditure measured during paralysis, sedation, barbiturate-induced coma and in rested, nonsedated patients. A frequency histogram of resting metabolic expenditure (RME), expressed as percent of expected RME, is shown for all collections. The mean value (± standard deviation) for nonsedated patients is 138% ± 37% of expected RME. The mean value for patients treated with sedation, paralysis, or barbiturate-induced coma was 89% ± 03%.

References

1.

Becker DPMiller JDWard JDet al: The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 47:4915021977Becker DP Miller JD Ward JD et al: The outcome from severe head injury with early diagnosis and intensive management. J Neurosurg 47:491–502 1977

2.

Beisel WRSawyer WDRyll EDet al: Metabolic effects of intracellular infections in man. Ann Intern Med 67:7447791967Beisel WR Sawyer WD Ryll ED et al: Metabolic effects of intracellular infections in man. Ann Intern Med 67:744–779 1967

3.

Bistrian BRBlackburn GLSherman Met al: Therapeutic index of nutritional depletion in hospitalized patients. Surg Gynecol Obstet 141:5125161975Bistrian BR Blackburn GL Sherman M et al: Therapeutic index of nutritional depletion in hospitalized patients. Surg Gynecol Obstet 141:512–516 1975

4.

Boothby WMSandiford I: Laboratory Manual of the Techniques of BMR Determination Section 3. Philadelphia: WB Saunders1920 pp 8287Boothby WM Sandiford I: Laboratory Manual of the Techniques of BMR Determination Section 3. Philadelphia: WB Saunders 1920 pp 82–87

5.

Calloway DHSpector H: Nitrogen balance as related to caloric and protein intake in active young men. Am J Clin Nutr 2:4054121954Calloway DH Spector H: Nitrogen balance as related to caloric and protein intake in active young men. Am J Clin Nutr 2:405–412 1954

6.

Clifton GLRobertson CSKyper Ket al: Cardiovascular response to severe head injury. J Neurosurg 59:4474541983Clifton GL Robertson CS Kyper K et al: Cardiovascular response to severe head injury. J Neurosurg 59:447–454 1983

7.

Cuthbertson DP: Observations on the disturbance of metabolism produced by injury to the limbs. Q J Med 1:2332461932Cuthbertson DP: Observations on the disturbance of metabolism produced by injury to the limbs. Q J Med 1:233–246 1932

8.

Daly JMVars HMDudrick SJ: Effects of protein depletion on strength of colonic anastomoses. Surg Gynecol Obstet 134:15211972Daly JM Vars HM Dudrick SJ: Effects of protein depletion on strength of colonic anastomoses. Surg Gynecol Obstet 134:15–21 1972

9.

Duke JH JrJørgensen SBBroell JRet al: Contribution of protein to caloric expenditure following injury. Surgery 68:1681741970Duke JH Jr Jørgensen SB Broell JR et al: Contribution of protein to caloric expenditure following injury. Surgery 68:168–174 1970

10.

Glickman NMitchell HHLambert EHet al: The total specific dynamic action of high-protein and high-carbohydrate diets on human subjects. J Nutr 36:41571948Glickman N Mitchell HH Lambert EH et al: The total specific dynamic action of high-protein and high-carbohydrate diets on human subjects. J Nutr 36:41–57 1948

11.

Kinney JM: Energy deficits in acute illness and injury in Morgan AP (ed): Proceedings of the Conference on Energy Metabolism and Body Fuel Utilization. Cambridge, Mass: Harvard University Press1966 p 173Kinney JM: Energy deficits in acute illness and injury in Morgan AP (ed): Proceedings of the Conference on Energy Metabolism and Body Fuel Utilization. Cambridge Mass: Harvard University Press 1966 p 173

12.

Law DKDudrick SJAbdou NI: The effects of protein calorie malnutrition on immune competence of the surgical patient. Surg Gynecol Obstet 139:2572661974Law DK Dudrick SJ Abdou NI: The effects of protein calorie malnutrition on immune competence of the surgical patient. Surg Gynecol Obstet 139:257–266 1974

13.

Long CLBirkhahn RHGeiger JWet al: Urinary excretion of 3-methylhistidine: an assessment of muscle protein catabolism in adult normal subjects and during malnutrition, sepsis, and skeletal trauma. Metabolism 30:7657761981Long CL Birkhahn RH Geiger JW et al: Urinary excretion of 3-methylhistidine: an assessment of muscle protein catabolism in adult normal subjects and during malnutrition sepsis and skeletal trauma. Metabolism 30:765–776 1981

14.

Long CLSchaffel NGeiger JWet al: Metabolic response to injury and illness: estimation of energy and protein needs from indirect calorimetry and nitrogen balance. JPEN 3:4524561979Long CL Schaffel N Geiger JW et al: Metabolic response to injury and illness: estimation of energy and protein needs from indirect calorimetry and nitrogen balance. JPEN 3:452–456 1979

15.

Owen OECahill GF Jr: Metabolic effects of exogenous glucocorticoids in fasted man. J Clin Invest 52:259626051973Owen OE Cahill GF Jr: Metabolic effects of exogenous glucocorticoids in fasted man. J Clin Invest 52:2596–2605 1973

16.

Soroff HSPearson EArtz CP: An estimation of the nitrogen requirements for equilibrium in burned patients. Surg Gynecol Obstet 112:1591721961Soroff HS Pearson E Artz CP: An estimation of the nitrogen requirements for equilibrium in burned patients. Surg Gynecol Obstet 112:159–172 1961

17.

Studley HO: Percentage of weight loss. A basic indicator of surgical risk in patients with chronic peptic ulcer. JAMA 106:4584601936Studley HO: Percentage of weight loss. A basic indicator of surgical risk in patients with chronic peptic ulcer. JAMA 106:458–460 1936

18.

Tomas FMMunro HNYoung VR: Effect of glucocorticoid administration on the rate of muscle protein breakdown in vivo in rats, as measured by urinary excretion of N-methylhistidine. Biochem J 178:1391461979Tomas FM Munro HN Young VR: Effect of glucocorticoid administration on the rate of muscle protein breakdown in vivo in rats as measured by urinary excretion of N-methylhistidine. Biochem J 178:139–146 1979

19.

Turell DJAlexander JK: Experimental evaluation of Weir's formula for estimating metabolic rate in man. J Appl Physiol 19:9469481964Turell DJ Alexander JK: Experimental evaluation of Weir's formula for estimating metabolic rate in man. J Appl Physiol 19:946–948 1964

20.

Wilmore DW: The Metabolic Management of the Critically Illed 2. New York: Plenum Medical1980 p 29Wilmore DW: The Metabolic Management of the Critically Ill ed 2. New York: Plenum Medical 1980 p 29

21.

Wilmore DWLong JMMason AD Jret al: Catecholamines: mediator of the hypermetabolic response to thermal injury. Ann Surg 180:6536691974Wilmore DW Long JM Mason AD Jr et al: Catecholamines: mediator of the hypermetabolic response to thermal injury. Ann Surg 180:653–669 1974

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