Nutritional Support of the Trauma Patient

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Nutritional Support of the Trauma Patient

• Manmeet Malik, MS IV

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The critically ill

• Nutritional support is an integral component of
  the care of the critically injured patient. The
  understanding of the metabolic changes associated
  with starvation, stress and sepsis has deepened
  over the past 20-30 years and along with this has
  come a greater appreciation for the importance of
  the timing, composition and route of nutritional
  support of the trauma patient.

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Metabolic changes

• ebb phase lasts 12-24 hours, characterized by
  fever, ? O2 consumption, ? body temp,
  vasoconstriction
• flow phase lasts for the remainder of the
  acute illness, hypercatabolism, utilization of
  fat as the major fuel source
• anabolic phase begins with onset of recovery,
  characterized by normalization of vital signs,
  improved appetite and diuresis.
• GOAL OF NUTRITIONAL SUPPORT maintain vital
  organ structure and function

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Overview of Nutrtional Support

• Route (TEN vs TPN)
• Timing (Early vs Late)
• Type (Standard vs Enhanced)
• Site (Gastric vs Jejunal)
• Assessment
• Monitoring

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Route

• TEN
• Advantages
• Physiologic
• Maintains mucosal integrity, minimizing risk of
  bacterial colonization
• Fewer septic complications
• Disadvantages
• Requires adequate gastric emptying
• Risk of aspiration
• Frequent interruptions in feeding necessitated by
  multiple trips to the OR

• TPN
• Advantages
• Does not require adequate gastric motility
• No risk of aspiration
• Disadvantages
• Intestinal mucosal atrophy
• Catheter related sepsis
• Expensive in relation to TEN

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SELECTED COMMERCIALLY AVAILABLE FORMULA DIETS
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BASIC DAILY REQUIREMENTS FOR TOTAL PARENTERAL
NUTRITION
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Recommendations

• Patients with blunt and penetrating abdominal
  injuries sustain fewer septic complications when
  fed enterally vs parenterally.
• Patients with severe head injuries have similar
  outcomes whether fed enterally or parenterally.

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Timing

• Early vs. Delayed
• Recomendations
• FEED AS SOON AS POSSIBLE!!!
• Early intragastric feedings (within 12 hours of
  burns) in burn patients to avoid gastroparesis
• Post-pyloric feedings (beyond the Ligament of
  Treitz) in patients with severe head injury who
  do not tolerate gastric feeding
• Direct small bowel feedings via nasojejunal
  feeding tubes, gastrojejunal tube, or feeding
  jejunostomy within 12-24 hours of injury in
  patients with blunt and penetrating abdominal
  injuries

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Type

• Standard
• TEN
• TPN

• Enhanced
• Addition of omega-3 fatty acids, nucleotides,
  arginine, beta-carotene, and/or glutamine

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Recommendations

• The use of enhanced enteral nutrition is
  beneficial to the trauma patient when given in
  conjunction with early feeding and adequate
  protein/calorie support

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Site

• Gastric vs. Jejunal
• Recommendations
• Whether it is preferable to feed into the stomach
  or jejunum is unclear, however, because access to
  the stomach can be obtained more quickly and
  easily than to the duodenum, an intial attempt at
  gastric feedings appears warranted (PEG)
• Patients at high risk for aspiration due to
  gastric retention (2 to obstruction or
  gastroparesis) or GERD should receive enteral
  feedings into the jejunum (nasojejunal feeding,
  PEGJ)

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Assessment

• Multiple formulae exist that provide at best only
  an estimate of an individual patients initial
  energy and substrate needs
• Energy requirements are calculated on the basis
  of basal energy expenditure (BEE) which is the
  amount of energy required to perform metabolic
  functions at rest
• Harris-Benedict equation
• Men BEE 66(13.7 x weight)(5 x height)-(6.8 x
  age)
• Women BEE655.1(9.6 x weight)(1.8 x
  height)-(4.7 x age)
• Calorie requirements/day 1.25 x BEE
• BMI, anthropometry, muscle function tests (hand
  grip and respiratory muscle strength), delayed
  cutaneous hypersensitivity

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Monitoring

• Patients receiving nutritional support should be
  closely monitored. Current data however does not
  address the frequency of monitoring or the
  efficacy of monitoring
• Baseline measurement and ongoing monitoring of
  serum pre-albumin, albumin, BUN, Cr, plasma
  electrolytes, glucose, Ca, Mg, Inorganic phos,
  total protein, Hgb, WBC, platelets,
  triglycerides, transaminases
• Regular weighing and measurements of IVF, feeds,
  and UO

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Monitoring contd

• Serum albumin most frequently used laboratory
  measure of nutritional status a value less than
  2.2g/dL generally reflects severe malnutrition.
  Reliability as a marker of visceral protein
  status is compromised by its long t1/2 of 14-20
  days
• Transferrin t1/2 of 9 days
• Prealbumin (transthyretin) most sensitive
  indicator of appropriate nutritional support,
  t1/2 of 24-48 hours
• Retinol Binding Protein

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Monitoring contd

• Monitoring nitrogen balance is the best method of
  assessing the effectiveness of supplemental
  nutritional therapy
• Nitrogen balance (protein intake/6.25) (UUN4)
  over 12 or 24 hours
• 0 to -5 moderate stress
• lt -5 severe stress

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Summary

• Critically ill patients are hypermetabolic and
  have increased nutritional requirements. Wound
  healing and normal immune responses are dependent
  upon adequate nutritional intake and therefore
  nutritional support must not be overlooked in the
  management of trauma patients.

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References

• http//www.guideline.gov/summary/summary.aspx?doc_
  id2961modefullss15
• http//www.rcsed.ac.uk/Journal/vol45_6/4560008.htm
  
• http//www.merck.com/mrkshared/mmanual/section1/ch
  apter1/1c.jsp
• www.uptodate.com (Assessment of nutrition in the
  critically ill, Nutritional issues in the
  surgical patient, Nutritional support in the
  critically ill)