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Sudden systemic metabolism changes after traumatic brain injury (TBI) includes hypercatabolism, hypermetabolism and hyperglycaemia. Adequate nutrition support needs to cater the increase in protein and energy need to prevent loss of lean body mass which could potentially increase risk of clinical complications.
CLIENT HISTORY:57 years old Indian male, a nursing home resident with history of type 2 diabetes mellitus, hypertension and mental illness, was admitted to hospital after being assaulted by his roommate. He suffered from Right Subdural Hemorrhagic, right humerus and facial bone fracture and right lung contusion. Craniotomy was done to remove blood clot.
ASSESSMENT:BMI=24kg/m2. Haemoglobin and electrolytes were low. Blood glucose was high. Patient was ventilated and sedated with propofol, 8ml hourly(1.1kcal/ml). He was on 50 ml clear fluid 3 hourly. Energy intake was 211 kcal/day and 0 g protein. Energy requirement was 2,091 kcal and 109.5g protein per day based on 140% of REE for non-paralyzed, protein: 15-20% of energy (Brain Trauma Foundation, 2000).
NUTRITION DIAGNOSIS:Inadequate energy and protein intake from enteral nutrition support related to target goal not achieved as evidence by patient received energy from propofol.
OBJECTIVE & NUTRIENT PRESCRIPTION:To optimize nutrition, promote wound healing and to prevent loss of lean body mass. Nutrient prescription suggested was continuous, low carbohydrate, hypercaloric (1.5 kcal/ml) enteral nutrition with initial rate of 30 to 58 ml hourly (min, max) through nasogastric tube (1,392ml, 2,088 kcal, 83.5 g protein).
OUTCOME AND F.UP:Patient tolerated feeding well as evidence by no vomiting and gastric residual volume and normal bowel output. NDx: inadequate protein intake related to goal not achieved as evidence by 83.5 g protein intake (requirement: 109.5g/day). Plan: supplement additional 20 g of modular protein.
DISCUSSION: Low carbohydrate formulation may be considered for hyperglycaemic TBI patients as a result of gluconeogenesis (catabolic state). Hypercaloric feed enable sufficient calories and protein at lower volume and shorter time to reach goals.
LEARNING POINTS
•TBI patients often suffers from feeding intolerance, requiring extensive feeding modifications
•Hypercaloric feeds and continuous feeding are strategies to meet nutrient goals in less than 3 days.
•Larger lumen size of tube need to be considered when when using hypercaloric and fibre EN.