51
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Affiliation(s)
- J M Meythaler
- Spain Rehabilitation Center, University of Alabama School of Medicine, Birmingham 35233-7330, USA
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52
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Suchner U, Senftleben U, Eckart T, Scholz MR, Beck K, Murr R, Enzenbach R, Peter K. Enteral versus parenteral nutrition: effects on gastrointestinal function and metabolism. Nutrition 1996; 12:13-22. [PMID: 8838831 DOI: 10.1016/0899-9007(95)00016-x] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
The effects of total parenteral nutrition (TPN) versus enteral nutrition (TEN) were studied in 34 patients following major neurosurgery. Measurements were made of resting energy expenditure (REE), urea production rate (UPR), visceral proteins, parameters of liver and pancreas function, as well as gastrointestinal absorption. To predict nutritional status, nutritional index (NI) was calculated. UPR revealed no significant differences between the groups. After 12 days of TEN, however, synthesis of visceral proteins increased significantly. In addition, NI improved after TEN (p < 0.05), whereas it remained unchanged after TPN. Thrombocyte and lymphocyte counts rose predominately during enteral nutrition. Only in the TEN group was REE increased by 18% and Glasgow Coma Scale (GCS) enhanced from Day 6 on. Exogenous insulin demand was enhanced in the parenterally fed group, and bilirubin (p < 0.05), amylase (p < 0.05), and lipase (p < 0.01) rose significantly, as did gamma-glutamyl-transferase (p < 0.0005) and alkaline phosphatase (p < 0.0005). After 12 d of TPN, vitamin A absorption was significantly attenuated, indicating reduced fat absorption compared to TEN. Carbohydrate absorption did not show significant changes between the groups. Only during TPN did mean values of xylose absorption remain below the normal range. Therefore, enteral nutrition following neurosurgical procedures is associated with an accelerated normalization of nutritional status and an improved substrate tolerance. TEN opposes early postoperative absorption disturbances of the small intestine.
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Affiliation(s)
- U Suchner
- Klinikum Grosshadern, Ludwig-Maximilians-Universität, München, Germany
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53
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Magnuson B, Hatton J, Zweng TN, Young B. Pentobarbital coma in neurosurgical patients: nutrition considerations. Nutr Clin Pract 1994; 9:146-50. [PMID: 8078453 DOI: 10.1177/0115426594009004146] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Neurosurgical patients in pentobarbital coma are a complex nutrition support population. Physiologic changes associated with the primary injury to the brain, combined with the pharmacodynamic influences of barbiturate therapy, contribute to the difficulties of initiating aggressive nutrition support. Early nutritional repletion is important to the overall outcome of traumatically injured patients. Consequently, factors that influence nutrition support decisions must be understood to assure appropriate intervention. The metabolic changes associated with traumatic head injury, pentobarbital therapy, and nutrition support strategies are reviewed.
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54
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Ziccardi VB, Ochs MW, Braun TW. Indications for enteric tube feedings in oral and maxillofacial surgery. J Oral Maxillofac Surg 1993; 51:1250-4. [PMID: 8018133 DOI: 10.1016/s0278-2391(10)80297-6] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
The catabolic effects of surgical trauma and sepsis have long been recognized. Oral and maxillofacial surgical patients represent a unique group in that their surgery and its effects on the stomatognathic system may adversely affect the ability to receive adequate nutrition. This article discusses some basic nutritional principles and describes the indications and guidelines for enteric tube feeding in this patient population.
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Affiliation(s)
- V B Ziccardi
- Department of Oral and Maxillofacial Surgery, University of Pittsburgh Eye and Ear Hospital, PA
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55
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Abstract
There are many common and significant medical complications of head injury. These include (1) cardiovascular problems such as hyperdynamic state, myocardial injury, and dysrhythmias; (2) respiratory changes such as neurogenic pulmonary edema, hypoxia, abnormal ventilatory patterns, pulmonary infections, and pulmonary emboli secondary to deep vein thrombosis; (3) consumption coagulopathy; (4) water and electrolyte derangements--hypo- and hypernatremia; (5) hypothalamic/pituitary dysfunction--syndrome of inappropriate secretion of antidiuretic hormone and diabetes insipidus; (6) increased general metabolism with loss of immunocompetence, respiratory compromise, and complications of decreased activity; (7) gastrointestinal difficulties, particularly stress gastritis; and (8) infectious problems including those related to contamination from open wounds and foreign bodies such as monitors.
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Affiliation(s)
- H H Kaufman
- Department of Neurosurgery, West Virginia University School of Medicine, Morgantown
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56
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57
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Zaloga GP. Parenteral versus Enteral Nutrition. UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 1993. [DOI: 10.1007/978-3-642-85011-0_15] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
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58
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Dickerson JW. Recovery from brain damage. Recovery of function: nutritional factors. ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 1992; 325:23-33. [PMID: 1290343 DOI: 10.1007/978-1-4615-3420-4_2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Affiliation(s)
- J W Dickerson
- School of Biological Sciences, University of Surrey, Guildford, England
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59
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Spinal Cord Damage with Diving Injuries: Considerations for Nursing Care. Crit Care Nurs Clin North Am 1991. [DOI: 10.1016/s0899-5885(18)30744-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
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60
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Young B, Ott L, Phillips R, McClain C. Metabolic Management of the Patient with Head Injury. Neurosurg Clin N Am 1991. [DOI: 10.1016/s1042-3680(18)30737-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
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61
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Abstract
Nutrition in acute spinal cord injury is complicated. Not every aspect of nutrition as it relates to the acutely injured spinal cord patient is known. The stress response to injury, fever, infection, sepsis, and surgery alter nutritional needs, as does the spinal cord injury itself. The sequelae of spinal cord injury, including denervation atrophy and paralysis, glucose intolerance, skin and wound breakdown, poikilothermy, anemia, respiratory paralysis, pneumonia, paralytic ileus, gastrointestinal ulcers and hemorrhage, neurogenic bowel and bladder, and depression, all affect the nutritional needs of the patient. Orthopedic appliances, pharmacologic agents, and other injuries can also alter nutritional requirements. Nutritional assessment in acute spinal cord injury is also complex. It should include medical and diet history, physical examination, intake and output measurements, prediction of energy expenditure and protein requirements, or--even better--measurements of energy expenditure with indirect methodology, using the metabolic cart or pulmonary artery catheter. Application of computerized tomography and radioisotope studies may prove valuable in the future. Finally, the direct relationship between nutrition and physiologic alterations of acute spinal cord injury necessitates that the critical care nurse incorporate nutrition-focused thinking into many aspects of the acute spinal cord--injured patient's care.
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62
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Hennessey PJ, Black CT, Andrassy RJ. Nonenzymatic glycosylation of immunoglobulin G impairs complement fixation. JPEN J Parenter Enteral Nutr 1991; 15:60-4. [PMID: 2008035 DOI: 10.1177/014860719101500160] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Transient hyperglycemia in patients receiving total parenteral nutrition may be associated with impaired immune function. The effects of short-term hyperglycemia on one aspect of antimicrobial immune function, ie, the ability of IgG to fix complement, were investigated. Aliquots of anti-human albumin, anti-horse ferritin, and anti-alkaline phosphatase were incubated for 0, 8, 16, 24, 48, and 96 hr with either 0 or 240 mg of glucose per deciliter of buffer. All samples were analyzed for the degree of glycation using a thiobarbituric acid assay, and for complement fixation ability using a microcomplement fixation assay. Significant increases in glycation over control samples were observed after only 16 hr (31 vs 15 mmol 5-hydroxymethylfurfural/mol IgG, p less than 0.01). Complement fixation was significantly altered after 48 hr of incubation (76 +/- 5% vs 90 +/- 8% total serum complement fixed by albumin/anti-albumin complex, p less than 0.03) when four of the 84 (4.7%) IgG lysine residues were glycated. It is demonstrated that a significant reduction in complement fixation by immunoglobulin occurs with elevated glucose concentrations and that this may play a clinically significant role in transiently hyperglycemic patients.
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Affiliation(s)
- P J Hennessey
- Department of Surgery, University of Texas Medical School, Houston, Texas 77030
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63
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Abstract
This review has discussed the current status of metabolic alterations and demands, nutrient administration, and nutritional assessment of the head-injured patient. More work is necessary in all areas to further describe and ascertain the nutritional requirements of these patients. Future research in this area should involve specific nutrient requirement, modification of the acute-phase response, and possibly administration of growth factors.
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64
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Chiolero RL, Thorin D, Schutz Y, Jequier E. [Energy metabolism and craniocerebral injury]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1990; 9:169-75. [PMID: 2194408 DOI: 10.1016/s0750-7658(05)80055-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Severe head injury induces major hormonal, humoral and metabolic changes, characterized by increases in stress hormone secretion, lymphokines production, associated with high lipid and protein catabolism as well as changes in energy expenditure (EE). Numerous factors influence EE in head-injured patients, particularly anthropometric data, body temperature, nutritional support, level of consciousness, muscular tone and activity. Resting EE is usually increased following brain trauma; however, normal or decreased metabolic rates can be observed in curarized patients on mechanical ventilation or in patients receiving high doses of barbiturates.
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Affiliation(s)
- R L Chiolero
- Service d'Anesthésiologie, Centre Hospitalier Universitaire Vaudois, Lausanne
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65
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Abernathy GB, Heizer WD, Holcombe BJ, Raasch RH, Schlegel KE, Hak LJ. Efficacy of tube feeding in supplying energy requirements of hospitalized patients. JPEN J Parenter Enteral Nutr 1989; 13:387-91. [PMID: 2506375 DOI: 10.1177/0148607189013004387] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
During a 6-week period, all adult patients in a university hospital receiving ready-to-feed nasoenteric tube feeding formula were prospectively studied. The study objective was to determine each patient's caloric intake from tube feeding relative to their energy needs and to identify factors causing decreased feeding intake. Each of 35 patients was visited at least once daily to determine their volumetric intake of tube feeding formula. Daily review of patient care records and nursing interviews were used to identify interruptions in therapy. Patient's basal energy expenditures (BEE) were calculated using the Harris-Benedict equation. Calorie goals were set by members of the Nutrition Support Service or clinical dietitians. Intakes averaged 1095 +/- 41 Kcal (SEM) per day or 61% of their mean calorie goal of 1791 +/- 41 Kcal. Mean daily calorie intake was statistically different (p less than 0.05) from mean energy goal on patient study days 1 through 5, 7, and 8. Only 16 of the 35 patients achieved an intake of 100% of their energy goal on any day of therapy. Calorie goals averaged 1.4 times BEE. Mean daily calorie intake did not exceed BEE until study day 10. Eighteen % of potential feeding time was lost due to temporary feeding interruptions; primarily inadvertent extubation (4.6%), gastrointestinal intolerance (4.7%), medical procedures requiring discontinuation of feeding (2.8%), and feeding tube positioning difficulties (1.5%). In addition, physicians ordered only 75% of calculated energy goals. These data indicate that tube feeding therapy, when provided under usual hospital conditions, does not meet patient's energy requirements.
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Affiliation(s)
- G B Abernathy
- Nutrition Support Service, North Carolina Memorial Hospital, Chapel Hill
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66
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Chioléro R, Schutz Y, Lemarchand T, Felber JP, de Tribolet N, Freeman J, Jéquier E. Hormonal and metabolic changes following severe head injury or noncranial injury. JPEN J Parenter Enteral Nutr 1989; 13:5-12. [PMID: 2926978 DOI: 10.1177/014860718901300105] [Citation(s) in RCA: 61] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
In order to evaluate the effect of head injury in severely traumatized patients on the response of plasma cortisol, glucagon, insulin, glucose, and FFA as well as urinary N and catecholamines excretions, 36 patients were prospectively studied over 5 consecutive days following injury. They were divided into three groups: group I, severe isolated head injury (n = 14); group II, multiple injury combined with severe head injury (n = 12); group III multiple injury without head injury (n = 10). The results demonstrate similar hormonal and metabolic changes between these three groups of patients, characterized by elevated urinary adrenaline, noradrenaline excretion, increased cortisol, glucagon, insulin plasma levels throughout the study and elevated N urinary excretion with strongly negative N balances during the first 5 days postinjury. A significant correlation was observed between N intake and 5 day cumulated N balance (r = 0.63, p less than 0.001). In addition, N balance was negatively correlated with urinary excretion of adrenaline (r = -0.47, p less than 0.01) and noradrenaline (r = -0.44, p less than 0.05) as well as plasma levels of glucagon (r = -0.44, p less than 0.05). Isolated severe head injury seems to induce a full response in the secretion of the catabolic counterregulatory hormones comparable to that encountered in patients with multiple injury and associated with a marked increase in protein catabolism; additional noncranial major injury does not seem to enhance these responses.
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Affiliation(s)
- R Chioléro
- Department of Anesthesiology, University Hospital CHUV, Lausanne, Switzerland
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67
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Bucci MN, Dechert RE, Arnoldi DK, Campbell J, McGillicuddy JE, Bartlett RH. Elevated intracranial pressure associated with hypermetabolism in isolated head trauma. Acta Neurochir (Wien) 1988; 93:133-6. [PMID: 3177029 DOI: 10.1007/bf01402895] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
Both metabolic rate and protein catabolism are known to increase following severe head trauma, but the etiology of this hypermetabolism is unknown. To further investigate the problem, we studied the metabolism of 17 patients with indirect calorimetry who had severe craniocerebral trauma only and who required ICP monitoring for management. Patients were studied daily and immediately after ICP spikes greater than 20 mm Hg, prior to treatment with hyperventilation, osmotic diuretics, or barbiturates. Oxygen consumption (VO2) was correlated with ICP. Two groups of patients were identified. Group I patients were treated with hyperventilation and osmotic diuretics while Group II patients additionally received cerebral metabolic depressants. Group I had a significant correlation coefficient between VO2 and ICP. Significant hypercatabolism early in the post trauma period was demonstrated by increased urine urea nitrogen. Our observations suggest that in patients with craniocerebral trauma, elevated ICP is associated with increased oxygen consumption, protein catabolism and systemic hypermetabolism. Cerebral metabolic depressants blunted increases in VO2 which were seen with elevated ICP.
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Affiliation(s)
- M N Bucci
- Department of Surgery, University of Michigan, Ann Arbor
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