ReviewNutrition therapy in the optimisation of health outcomes in adult patients with moderate to severe traumatic brain injury: Findings from a scoping review
Introduction
Traumatic brain injury (TBI), defined as an alteration in brain function or brain pathology resulting from an external force, is a pressing public health issue, with the World Health Organisation estimating that TBI will be the most prevalent cause of death and disability globally by 2020 [1], [2], [3]. An estimated 10 million cases of moderate to severe TBI (leading to mortality or hospitilisation), occur worldwide each year [3]. Interventions that aim to enhance and improve the speed and extent of recovery from head injury are needed.
Nutrition-based interventions have the potential to enhance recovery and was identified by the Brain Trauma Foundation in 2007 as a priority research area and one of the 15 key intervention types likely to influence outcomes in TBI patients [4]. Nutrition support is defined as the provision of additional nutrition via the parenteral (non-gastrointestinal route direct to the blood stream), or enteral route (via the nasal route using a nasogastric, nasoduodenal, or nasojejunal tube, or directly through the abdomen using a gastrostomy, gastrojejunostomy, or jejunostomy feeding tube) [5]. Nutrition therapy, which also includes the oral route, goes beyond nutrition support as a component of medical treatment aimed at maintaining or restoring optimal nutrition status and health [5]. In addition to the usual difficulties associated with the provision of nutrition therapy to critically-ill patients, optimal nutrition therapy in patients with moderate to severe TBI is made more complex by some unique physiological challenges.
Post-TBI, metabolic changes result in an increase in energy requirements that can vary between 87% and 200% above usual values, extending up to 30 days post-injury [6]. This hypermetabolic response is thought to result from an increased production of corticosteroids, counter-regulatory hormones such as epinephrine, norepinephrine and cortisol, and pro-inflammatory mediators and cytokines such as interleukin-1 (IL-1), IL-6, IL-12, tumour necrosis factor-alpha (TNF-α), and interferon-gamma [7], [8], [9], [10]. Whether these inflammatory markers can be used diagnostically to predict the influence of specific interventions on long-term outcomes is yet to be determined, but markers that correlate with the severity of disease and demonstrate prognosis are being sought [8], [11]. Hypermetabolism can lead to the hypercatabolism of macronutrients, resulting in negative nitrogen balance, and substantially increased energy and protein requirements [6], [12], [13]. Hypercatabolism coupled with immobility can lead to an increased risk of malnutrition in the severely ill [14]. Nutritional requirements are further elevated by wound healing in cases of TBI with multi-trauma [15]. In one of the few studies on this topic, Krakau and colleagues demonstrated that approximately 68% of patients show signs of malnutrition within two months of head injury [16]. Dhandapani and colleagues showed that malnutrition has undesirable consequences with poor Glasgow Outcome Scale (GOS) at six months post-injury [17].
The difficulties in meeting increased nutrition requirements in TBI may be compounded further by dysphagia, gastrointestinal intolerance due to gastroparesis, fasting pre-surgery, and medication complications [6], [18], [19]. Post-traumatic amnesia, a state of altered consciousness associated with the recovery process, often results in inadvertent removal of feeding tubes and food refusal [12]. In many hospitals, nursing staff lack the capacity to provide the amount of assistance sufficient to ensure that the most difficult TBI patients get the nutrition they need [20], [21].
Although it is clear that increased nutrition is required following TBI, it is less evident which aspects of nutrition therapy lead to better outcomes. A systematic review of publications between 1993 and 2003 [22] examined the evidence for effects of different timing, content, and method of administration of nutritional treatment on early and long-term clinical outcomes in patients with moderate to severe TBI. The reviewers concluded that the evidence base for determining the effect of nutrition support is insufficient, particularly in the post-injury phase [22]. Three other systematic reviews [23], [24], [25] on nutrition therapy in TBI were published in 1996, 2000, and 2002 however these have since been updated [26], [27], but not synthesised. Since these reviews were published, the influence of nutrient delivery in TBI, specifically immunonutrients, has emerged as an area of scientific interest. The extent of research and best practice with regards to nutrient provision in TBI is unknown, and questions regarding optimal timing of introduction of feeding, rate of achievement of nutrient targets, method of nutrient delivery, and feeding environment, remain.
The aim of the current scoping review was to summarise the current literature in the area of nutrition therapy and TBI, and to investigate the influence of nutrition therapy on outcome measures of mortality, morbidity (measured using Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS), Acute Physiology and Chronic Health Evaluation II (APACHE II)), and length of hospital/intensive care unit (ICU) stay, most commonly collected in the moderate to severe TBI population. The objective of the scoping review was to address the impact of four areas of nutrition therapy: (1) timing of feed provision; (2) route of administration of feeding; (3) the type of nutrients provided, including immunonutrients; and (4) the feeding environment.
Section snippets
Methods
Scoping reviews aim to identify and describe evidence in broad topic areas, such as nutrition therapy following TBI, that encompass a range of interventions and outcome measures. Like systematic reviews, they should include a comprehensive search and reproducible transparent methods for inclusion, evaluation, analysis and reporting. However, unlike systematic reviews, they usually focus on breadth of research activity and reported findings, rather than detailed independent quality appraisal and
Results
The initial database search identified 1574 unique articles within individual databases. After 150 duplicates across databases were removed, 1432 articles remained. Title and abstract screening led to the retrieval of 85 potentially-relevant articles for assessment. One article was identified from a previous Google search and included in the analyses. Separate searches of the GEM and ERABI databases found two studies that met inclusion criteria. Seven articles were identified for retrieval from
Discussion
This scoping review examined the evidence on nutrition therapy in TBI, identifying a range of research topics previously not captured by systematic reviews or meta-analyses, including provision of nutrients and immunonutrition. No published research about the feeding environment was found. Nutrition therapy appears to be an under-researched area and evidence that does exist is equivocal. Practitioners therefore lack evidence-based guidance on the optimal timing of initiation or administration
Author contributions
This scoping review formed part of LSC's postgraduate studies. LSC, LTW, FEL were responsible for design of the study, development of the search strategy, screening of the studies, performing data extractions, and interpretation of results, and contributed to all drafts of the manuscript. LSC conducted the search and retrieval, drafted the initial paper, and is responsible for the final content. RLG made critical revision of the manuscript for intellectual content and contributed to drafts of
Conflict of interest statement
There are no conflicts of interest, copyright constraints, or industry funding to report for any of the authors. The views expressed in this article are those of the authors and do not reflect the policy or position of any institution.
Acknowledgement
The authors of this article would like to thank Emma Agnew for her assistance in retrieving journal articles.
References (58)
- et al.
Position statement: definition of traumatic brain injury
Arch Phys Med Rehabil
(2010) - et al.
The systemic response to brain injury and disease
Brain Behav Immun
(2012) - et al.
Systemic inflammation after trauma
Injury
(2007) The metabolic response to stress: a case of complex nutrition support management
Crit Care Nurs Clin North Am
(2004)- et al.
Nutritional treatment of patients with severe traumatic brain injury during the first six months after injury
Nutrition
(2007) - et al.
Clinical malnutrition in severe traumatic brain injury: factors associated and outcome at 6 months
Indian J Neurotrauma
(2007) - et al.
Outcome following moderate traumatic brain injury
Surg Neurol
(2003) - et al.
Comparison of the efficacy of parenteral glutamine and branched-chain amino acid solutions given as extra supplements in parallel to the enteral nutrition in head trauma
e-SPEN
(2008) - et al.
Nutritional support in head injury
Nutrition
(2011) - et al.
Basics in clinical nutrition: nutritional support in trauma
e-SPEN
(2010)
Early management of severe traumatic brain injury
Lancet
Epidemiology of head injury
J Neurol Neurosurg Psychiatry
The impact of traumatic brain injuries: a global perspective
NeuroRehabilitation
Guidelines for the management of severe traumatic brain injury
J Neurotrauma
What is nutrition support therapy?
Hypermetabolism following moderate to severe traumatic acute brain injury: a systematic review
J Neurotrauma
The metabolic response to acute traumatic brain injury and implications for nutritional support
J Head Trauma Rehabil
The role of markers of inflammation in traumatic brain injury
Front Neurol
A consideration of biomarkers to be used for evaluation of inflammation in human nutritional studies
Br J Nutr
A reappraisal of nitrogen requirements for patients with critical illness and trauma
J Trauma Acute Care Surg
Protein catabolism and requirements in severe illness
Int J Vitam Nutr Res
Wound healing in sepsis and trauma
Shock
Enteral nutrition in patients with severe traumatic brain injury: reasons for intolerance and medical management
Br J Neurosurg
Dysphagia in severe traumatic brain injury
Neurosciences
Using dietetic assistants to improve the outcome of hip fracture: a randomised controlled trial of nutritional support in an acute trauma ward
Age Ageing
Hungry in hospital?
Metabolism and nutrition in patients with moderate and severe traumatic brain injury: a systematic review
Brain Inj
Guidelines for the management of severe head injury
Eur J Emerg Med
Management and prognosis of severe traumatic brain injury
Cited by (26)
Calorie and protein intake in traumatic brain injury patients
2023, Diet and Nutrition in Neurological DisordersDetermination of calorie and protein intake among acute and sub-acute traumatic brain injury patients
2020, Chinese Journal of Traumatology - English EditionCitation Excerpt :Generally, the injury causes abnormality of cellular metabolism, hormonal changes, and systemic inflammation response. Calorie expenditure among TBI patients usually increase by 87%–200% above the usual requirement and may be elevated for 30 days due to metabolic changes.6,9 Hormonal changes increase the production of corticosteroids, counter-regulation hormones, and cytokines which may cause the patient to develop hyper-metabolism state.10–12
Traumatic Brain Injury
2020, Braddom's Physical Medicine and RehabilitationPotential therapeutic implications of ergogenic compounds on pathophysiology induced by traumatic brain injury: A narrative review
2019, Life SciencesCitation Excerpt :It is important to note that formulas containing elevated nutrient levels associated with immune modulation may positively influence immune response to stress in adult surgical and trauma patients [219]. Promising results from the feeding of enteral diets with specific additives, such as glutamine, arginine, omega-3 fatty acids, probiotics, symbiotics, and nucleotides have been reported recently, with various studies suggesting decreased septic complications, hospital costs or even mortality rates [220–222]. In this context, the understanding of how supplemental compounds, such as glutamine, may be applied to prevent or attenuate TBI-induced neurological dysfunction is extremely important.
A randomized controlled trial protocol for people with traumatic brain injury enrolled in a healthy lifestyle program (GLB-TBI)
2019, Contemporary Clinical Trials CommunicationsCitation Excerpt :Weight gain in people with TBI can often be attributed to environmental (e.g., accessibility; social support) and injury-specific factors such as impaired mobility, neurological dysfunction, medications, and changes in metabolic processes [4–7]. Subsequently, weight gain increases the risk of chronic diseases such as diabetes, metabolic syndrome, pulmonary and heart disease [8–10]. Effective approaches to weight-loss are lacking, yet necessary, due to the unique physiological and cognitive needs of persons with TBI [11,12].