The Initiation of Enteral and Parenteral Feeding and its Effect On Morbidity and

Mortality Rates After Traumatic Brain Injury

By:

Jaclyn Kiernan

Jackie.kiernan1492@gmail.com

University of Rhode Island

Masters of Science in Dietetics

February 21, 2017

Introduction:

Each day approximately 138 people die following a traumatic brain injury (TBI).1

A TBI occurs when a bump, blow or other head injury causes damage to the brain. 1

People who survive a TBI often are left with extreme disabilities such as difficulty

walking and speaking. A TBI can also lead to psychological changes including

depression, personality disorders, memory impairment, sensory disorders and impaired

thinking.1 The effects of a TBI often last a lifetime and cannot be reversed.1

Within the first 2-6 hours following a traumatic brain injury the body depletes all

of its glycogen stores due to a higher caloric need.2 The priority of the body is to protect

the brain from sepsis and promote healing.3 Since the body breaks down skeletal tissue

and various muscles to provide the brain with an adequate amount of glucose, a higher

amount of Calories and protein are needed to replete the body.2 Studies demonstrate that

TBI patients with a poor nutrition status experience worse clinical outcomes including an

increased mortality risk.4 Patients need as many as 35-40 kcal/kg due to a large increase

in metabolic rate.5 Protein needs are also increased to 1.5-2.2 g/kg.5 Vitamin levels

should also be monitored following a TBI. 5

While there are multiple causes of TBIs, during the years 2001-2010 the leading

cause was falls.1 There are currently no global nutrition parameters regarding the timing

of the initiation of feeding, the type of feeding preferred and the route of the feed.5

Immune mechanism impairment and muscle depletion following a TBI often lead to poor

clinical outcomes.6 The patients injuries following a TBI also pose issues such as
optimal timing and route of nutrition.7 Alternate means of nutrition support then become

vital for TBI patients.6

Enteral feeding is defined as the route of feeding that utilizes the gastrointestinal

tract such as an oral tube or a feeding tube.8 When compared with parenteral feeding,

enteral is often the preferred route since it utilizes the digestive tract.3 Tube feeding is a

liquid formula that contains carbohydrates, protein and fat and is given through on oral

tube (nasogastric tube) or a feeding tube (percutaneous endoscopic gastronomy tube or

jejunum tube).3 Since enteral feeding utilizes the gastrointestinal tract it prevents atrophy

of the digestive tract.3

While enteral feeding is provided through a feeding tube, parenteral feeding is

provided intravenously.3 The liquid mixture provided to patients provides an adequate

amount of protein, carbohydrates and fats needed for survival.3 Parenteral nutrition is

used when a patient has no use of his/her gut.3

Currently, there are no global parameters for clinicians to follow after a patient

suffers from a TBI.3 Due to the lack of global parameters there is no protocol regarding

when feeding should be initiated, what type of feeding should be initiated or what route

of feeding is best for traumatic brain injury patients.3

The morbidity and mortality rates of multiple TBI patient groups is expected to

provide evidence of the most appropriate time to initiate feedings, the most appropriate

route of feeding and the most appropriate method of feeding. The morbidity rate is

defined as the frequency with which a disease appears in a population.9 Mortality rate is

defined as the measure of the number of deaths in a particular population, scaled to the

size of that population per unit of time.9

Methods & Materials:

This narrative literature review is limited to studies conducted within the years

2011-2016 regardless of the setting of the study. Each study analyzed the effects of

enteral feeding and parenteral feeding on clinical outcomes following a traumatic brain

injury. Eligible articles were identified and reviewed through PubMed and Google

Scholar. The following key terms and combinations of key terms were used enteral

feeding, enteral, traumatic brain injury, TBI, brain injury, timing, initiation,

morbidity rate, mortality rate, clinical outcomes. These key terms led to 591

results. Articles were eliminated if the title alone demonstrated the study was not

appropriate or useful for the purposes of this narrative literature review or if the study had

been conducted prior to 2011. The search for articles was conducted during the time

frame of September 2016- January 2017.

All articles included in the narrative literature review were written in English and

any articles not written in the English language were excluded. The studies included in

this narrative literature review used observational, longitudinal, cross sectional, cohort,

randomized double blind and meta-analysis.

Discussion:

Meeting Energy Needs For TBI Patients:

Malnutrition is a common problem in the hospital setting and affects about 50%

of patients.4 Several studies have shown that early feeding can provide exogenous
substrates, protect visceral protein and fat, improve immune competence, reduce

infection and complications, promote neurological recovery and decrease fatalities.9

Traumatic brain injury acutely increases metabolic rate and pro-catabolism

leading to a need for increased Calories and protein, which often arent met, leaving TBI

patients malnourished.2 Observational data consistently show that during the initial phase

after moderate to severe TBI, when patients are in the ICU they are substantially

underfed.10 Both energy and protein deficits are associated with worse outcomes both for

TBI patients and ICU patients.10

Timing of Feeds:

While the American Association of Neurological Surgeons recommends full

nutrition replacement for a TBI patient by the seventh day, there isnt any definitive

evidence demonstrating that feeding prior to the seventh day will improve the outcome.11

Malakouti et al. examined 193 participants. Of the 193 participants 101 had

experienced a TBI while 92 had not. Fifty participants were provided nutritional support

within 48 hours of hospitalization. Eighty-three participants were provided with

nutritional support within 72 hours. All 193 participants received enteral nutrition while

13 also received TPN. It was not stated whether or not the participants receiving the TPN

had experienced a traumatic brain injury. Participants met a total of 47% Calorie goals

and 40% protein goals. The study concluded that the time of nutrition support initiation

did not affect the clinical outcome.9

Hartl, Gerber, Quanhong & Ghajar examined 1261 TBI patients who scored <9 on

the Glascow Coma Scale. The study concluded that patients that werent fed within 5-7

days following a traumatic brain injury had a 2 and 4 fold increased likelihood of death.
It was also noted that the amount of nutrition provided within the first 5 days of initiation

of nutrition support was related to mortality.12 For every 10 kcal/kg decrease there was a

30-40% increase in mortality rates.12

A total of 59 TBI patients acted as participants in the Chourdakis et al. study.

Participants ranged from ages 18-70 years old and had a TBI with a Glascow Coma Scale

score of > 9. Enteral nutrition was initiated 76.54 + 22.56 hours after the TBI patient was

admitted to the hospital while the delayed enteral feeding group had feeding initiated

31.23 + 11.18 hours after admission. The mortality rates did not differ amongst the two

groups (p= 0.693) but the total energy provided was increased in the early enteral feeding

group.13 This study concludes that the timing of enteral feeding initiation did not affect

mortality rates.13

After examining 16 studies focused on TBI and enteral nutrition for a meta-

analysis Wang et al. concluded that there are many benefits to early nutrition support

initiation. Some of the benefits mentioned include reduced mortality rates, improving

functional outcome and decreasing complications. Small bowel feedings are

recommended over EN and PN as well. Since small bowel feedings are not always

available Wang et al. recommends initiating EN as soon as possible.14

Route of the Feed:

Meirelles & Aguilar Nascimento studied a total of 22 traumatic brain injury

patients, 12 participants received enteral nutrition (EN) while 10 participants received

total parenteral nutrition (TPN). After being fed all participants experienced an increase

in glucose, participants receiving TPN, however, experienced a larger increase than

participants receiving EN. Meirelles & Aguilar Nascimento concluded that the route of

feeding did not influence early inflammation response or the clinical outcome. The study

concluded with a 9.1% mortality rate with one case in the EN group and one case in the

PN group.15

Fan et al. examined 120 participants ages 16-68 years old with a TBI and

separated them into three separate groups, EN, PN, and EN + PN with 40 participants in

each group. While the PN group experienced a decrease in serum protein, albumin,

prealbumin and hemoglobin (p<0.01) the EN group experienced a smaller decrease in

serum albumin, total protein, prealbumin and hemoglobin (p<0.05). The EN + PN group

experienced an increase in serum total protein, albumin, prealbumin and hemoglobin.16

Mazaherpur et al. examined 60 patients following a TBI. The 60 patients were

separated into 3 separate groups- EN, PN and EN + PN. While all three groups didnt

meet total energy needs the combination EN + PN group received more Calories (53.1 +

18.3%) greater than both the PN group and the EN group. The combination EN + PN

group also received a higher protein intake than both the EN and PN groups. The

survival rate amongst all three groups was 41.7% and there were no anthropometric

differences found amongst the three groups. The study concluded that neither EN or PN

can meet caloric needs alone.17 Studies conclude that EN + PN should be the preferred

method for TBI patients since it had the smallest mortality rate.16,17

Saran et al. examined 1495 patients, 1407 patients received a G tube (EN) feeding

while 88 patients received a small bowel feeding. Both groups met their caloric needs.

The gastric tube group experienced a 15.7 % mortality rate within 60 days. The small

bowel feeding group experienced a 20.5% mortality rate within 60 days. A higher
survival rate was seen with TBI patients who received EN as opposed to no EN for

Chiang et al. The non EN group had a larger amount of deaths while the survival rate of

the EN patients was higher (p= 0.005). This study examined 297 participants, 152 non

EN and 145 EN from 18 different hospitals. This concludes that EN should be the

preferred method of feeding for TBI patients.18,20

Chapple et al. examined 1045 patients amongst 31 ICUs. It was found that 94%

of patients were fed enterally but received only 58% total energy needs and 53% total

protein needs. This meta analysis concluded that patients with nutritional deficits have

increased mortality risk rates.10

Limitations of Previous Research:

While all studies reviewed examined the effects of alternate means of nutrition on

morbidity and mortality rates, the research looks at a variety of traumatic brain injuries

with very different Glasgow Coma Scores. Additionally, the TBI patients nutritional

status prior to the TBI was never mentioned, which has the opportunity to change the

outcome.

Future Research:

Current research provides unclear evidence regarding which route of feeding is

favorable and when feeding should be initiated. However, research does demonstrate that

meeting Calorie and protein needs while preventing nutrition deficiencies is essential for

decreased mortality rates. It is still currently uncertain whether EN or PN should be used.

Future research should examine the effects of both EN and PN together.

Summary:
 The amount of nutrition delivered within the first five days following a traumatic

brain injury is associated with decreased mortality rates.12 If a TBI patient does not

receive adequate nutrition within the first five days of nutrition support the likelihood of

death increases.12 Within the first 2-6 hours following a TBI the body depletes its

glycogen stores and fights to protect the brain from sepsis and begins to attempt healing.3

Following the depletion of glycogen stores, a patients risk for starvation increases, which

in turn will increase the likelihood of death.12 In addition, vitamin levels should also be

monitored for deficiencies which may also increase morbidity and mortality rates.5

Currently, there are not any global parameters or protocols in place. After

reviewing the literature, the appropriate time of initiation and route of feeding is unclear

due to inconclusive evidence. However, it is clear that it is essential for patients to meet

Calorie and protein needs or risk increased mortality rates.18

There was no difference in mortality rates when comparing the time of initiation

for feedings.9, 13 Also, it is also still unclear which route of feeding is most favorable.

Both enteral and parenteral nutrition when provided to patients separately led to no

difference in mortality rates.13,15, 16 When both enteral nutrition and parenteral nutrition

were provided to a patient following a TBI, the patient was more likely to achieve Calorie

and protein needs which led to a decreased mortality rate.16

The initiation of enteral nutrition led to better overall clinical outcomes but

patients did not always achieve Calorie needs.7, 14, 17 Patients who received enteral

nutrition also had higher cognitive scores in rehab centers than patients who didnt

receive enteral nutrition.7

 The decision as to when to initiate enteral or parenteral nutrition remains unclear

due to inconclusive evidence, however, most studies found that it is essential for patients

to receive adequate Calories and protein to survive following a TBI.

Future Implications:

Since evidence is strong that patients need an increased amount of Calories and

protein following a traumatic brain injury, the priority focus should be to ensure each

patient meets both Calorie goals and protein goals. In order to achieve such high Calorie

and protein goals both enteral and parenteral nutrition should be provided to patients

within 5 days of a TBI. Dietitians and doctors should consider using a concentrated

formula with at least a 1.5 kcal/mL rate to ensure Calorie goals are achieved.

Even though it is unclear if the timing of the initiation of feedings affects

mortality rates it is best to initiate within the first few days to prevent malnutrition and

vitamin deficiencies. Since glycogen stores are depleted the body will not only have to

replete the stores but it will also be burning extra Calories while attempting to prevent

sepsis and promote healing. An earlier initiation will allow more time for the body to

receive Calories and protein and for inflammation in the body to decrease as the body

begins to heal.
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