Assessment of nutritional requirements of head-injured patients

Restricted access

✓ A nomogram is presented for estimation of energy expenditure at the bedside in comatose patients during the first 2 weeks after brain injury. In analysis of 312 days of energy expenditure in 57 patients, a combination of Glasgow Coma Scale (GCS) score, heart rate (HR), and days since injury (DSI) was found with multiple regression analysis to provide good prediction of resting metabolic expenditure (RME) according to the following relationship: %RME = 152 − 14(GCS score) + 0.4(HR) + 7(DSI) (n = 111, r = 0.7, p < 0.001). In non-comatose patients, predictive ability was less strong due to inability to measure truly rested values, but HR and GCS score could be used to predict energy expenditure by this relationship: %RME = 90 − 3 (GCS score) + 0.9 (HR) (n = 135, r = 0.47, p < 0.001). In six patients, paralysis was found to decrease energy expenditure to between 100% and 125% of expected. Movement or stimulation had little effect on energy expenditure in patients who could localize stimuli but increased rested values by 20% in posturing patients.

Analysis of fasted balance periods of nitrogen excretion in 22 patients based on 273 days of measurement showed a significant relationship between creatinine-height index (an index of muscle mass) and nitrogen excretion, but no relationship between nitrogen excretion and weight, temperature, and RME. Levels of retention of nitrogen with feeding could not be predicted by any of these variables. Feeding of the individual comatose patient is best guided at present by estimation of energy expenditure using a nomogram and periodic measurement of urinary nitrogen excretion.

Article Information

Address reprint requests to: Guy L. Clifton, M.D., Division of Neurosurgery, Medical College of Virginia, P.O. Box 433 MCV Station, Richmond, Virginia 23298.

Address for Dr. Choi: Department of Biostatistics, Medical College of Virginia, Virginia Commonwealth University, Richmond, Virginia.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    The effect of paralysis with pancuronium bromide upon resting metabolic expenditure in six patients. Paralysis decreased energy expenditure to 100% to 125% of expected levels in all patients.

  • View in gallery

    A nomogram for estimation of caloric expenditure with an assumed heart rate (HR, per min) is shown. Movement and stimulation during half the day increase these values by approximately 20% in posturing patients but has a negligible effect unless extreme in patients who do not posture or who are not in coma. Resting metabolic expenditure (RME) values of 200% of expected levels or greater are found in patients who posture to stimulation and have increased muscle tone, sweating, and fever.

  • View in gallery

    Left: The mean resting metabolic expenditure (RME, % of expected values) and Glasgow Coma Scale (GCS) scores are shown with standard deviations for 11 patients admitted in coma who had a prolonged alteration in consciousness. The rise in RME between Weeks 1 and 2, and 2 and 3 is statistically significant as is change in GCS scores. All values were obtained during rest, but environmental stimulation increased RME as GCS scores improved. Right: Mean values with standard deviations for nitrogen intake and nitrogen balance are shown for the same 11 patients. Nitrogen intake significantly increased between the 1st and 2nd weeks, as did nitrogen balance. Nitrogen intake was unchanged between the 1st and 2nd weeks but nitrogen balance significantly improved. Protein catabolism was improved by the 3rd week but, despite a nitrogen intake of 15 gm/24 hrs, nitrogen balance remained negative.

References

1.

Calloway DHMargen S: Variation in endogenous nitrogen excretion and dietary nitrogen utilization as determinants of human protein requirement. J Nutr 101:2052161971Calloway DH Margen S: Variation in endogenous nitrogen excretion and dietary nitrogen utilization as determinants of human protein requirement. J Nutr 101:205–216 1971

2.

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

3.

Clifton GLRobertson CSContant CF: Enteral hyperalimentation in head injury. J Neurosurg 62:1861931985Clifton GL Robertson CS Contant CF: Enteral hyperalimentation in head injury. J Neurosurg 62:186–193 1985

4.

Clifton GLRobertson CSGrossman RGet al: The metabolic response to severe head injury. J Neurosurg 60:6876961984Clifton GL Robertson CS Grossman RG et al: The metabolic response to severe head injury. J Neurosurg 60:687–696 1984

5.

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

6.

Gadisseux PWard JDYoung HFet al: Nutrition and the neurosurgical patient. J Neurosurg 60:2192321984Gadisseux P Ward JD Young HF et al: Nutrition and the neurosurgical patient. J Neurosurg 60:219–232 1984

7.

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

8.

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

9.

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

10.

Rapp RPYoung BTwyman Det al: The favorable effect of early parenteral feeding on survival in head-injured patients. J Neurosurg 58:9069121983Rapp RP Young B Twyman D et al: The favorable effect of early parenteral feeding on survival in head-injured patients. J Neurosurg 58:906–912 1983

11.

Robertson CSClifton GLGoodman JC: Steroid administration and nitrogen excretion in the head-injured patient. J Neurosurg 63:7147181985Robertson CS Clifton GL Goodman JC: Steroid administration and nitrogen excretion in the head-injured patient. J Neurosurg 63:714–718 1985

12.

Robertson CSClifton GLGrossman RG: Oxygen utilization and cardiovascular function in head-injured patients. Neurosurgery 15:3073141984Robertson CS Clifton GL Grossman RG: Oxygen utilization and cardiovascular function in head-injured patients. Neurosurgery 15:307–314 1984

13.

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

14.

Teasdale GJennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81841974Teasdale G Jennett B: Assessment of coma and impaired consciousness. A practical scale. Lancet 2:81–84 1974

15.

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

16.

Welsh FAGinsberg MDRieder Wet al: Deleterious effect of glucose pretreatment on recovery from diffuse cerebral ischemia in the cat. II. Regional metabolite levels. Stroke 11:3553631980Welsh FA Ginsberg MD Rieder W et al: Deleterious effect of glucose pretreatment on recovery from diffuse cerebral ischemia in the cat. II. Regional metabolite levels. Stroke 11:355–363 1980

17.

Wilmore DW: The Metabolic Management of the Critically IIIed 2. New York: Plenum Medical1980 p 36Wilmore DW: The Metabolic Management of the Critically III ed 2. New York: Plenum Medical 1980 p 36

TrendMD

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 159 159 56
Full Text Views 258 258 9
PDF Downloads 128 128 9
EPUB Downloads 0 0 0

PubMed

Google Scholar