Maintaining Adequate Nutrition for People with Disorders of Consciousness: Challenges for Dietitians Laura Collett Neurosciences Dietitian King’s College Hospital NHS Foundation Trust Nutrition in Traumatic Brain Injury Nutrition in Traumatic Brain Injury The metabolic alterations that occur are multifactorial consisting of: - Hormonal changes - Abnormal cellular metabolism - Cerebral and systemic inflammatory response Subsequently contributing to: - Systemic catabolism - Hyperglycaemia - Protein catabolism - Increased energy requirements (Cook et al., 2008) Acute Injury- dietetic challenges Early Enteral Nutrition (within 24-48hours) Research suggests that it: - Reduces the breakdown of protein and fat stores - Reduce the inflammatory response - Promotes immune competence - Results in fewer infective complications (Perel et al., 2006; Taylor et al., 1999) - Improved neurological outcome at 3 months (Taylor et al., 1999) - Trend towards better outcomes in terms of survival (Hartl et al., 2008; Perel et al., 2006) - Consider Guidelines (McClave et al., 2009; Kreyman et al., 2006) Acute Injury – Dietetic Challenges Factors which increase energy expenditure Factors which reduce energy expenditure Weaning from mechanical ventilation Loss of body weight reduces resting energy expenditure Decerebrate rigidity Sedation Increased activity Paralysis (due to neuromuscular blocking agents) Pyrexia/sepsis Hypermetabolism (Thomas and Bishop 2007) Acute Injury – Dietetic Challenges Underfeeding - Impaired organ function - Poor wound healing - Altered immunological status - Increased mortality in traumatic brain injury - 797 patients with a GCS < 9 across 22 trauma centres - Significant improvement in mortality associated with every 10kcal/kg increase in intake, up to 25kcal/kg. - Conferred the most benefit in those with elevated intracranial pressure (Hartl et al., 2008) Acute Injury – Dietetic Challenges Overfeeding Carbohydrate: - Hypercapnia - Hyperglycaemia - Increased requirement for mechanical ventilation Protein: - Azotemia - metabolic acidosis Fat: - Hepatic steatosis - hypertriglyceridemia (Klein et al., 1998) Acute Injury – Dietetic Challenges Feed Tolerance Impaired gastrointestinal function has been reported in 80% of TBI patients with GCS < 12 (Kao et al., 1998) - sedation - metabolic state - raised intracranial pressure Gastroparesis  aspirates of > 250ml increased risk of vomiting, aspiration, infection. - However, evidence is lacking from prospective RCT’s - No standard definition on what a large aspirate is (DeLegge 2011) Acute Injury – Dietetic Challenges Feed Tolerance - Aspirate stomach contents 4 hourly - Monitor abdominal distension - Monitor emesis Management - Head of bed elevation 30-45degrees - Prokinetic agents – ? Metaclopramide + Erythromycin (Dickerson et al., 2009) - Concentrated feed formulas (>1.5kcal/ml) - Post pyloric feeding – Nasojejunal tubes, jejunostomy - Parenteral Nutrition Acute Injury – Dietetic Challenges Nutrition and Dietetic Care Process (British Dietetic Association, 2009) Post Acute Injury – Dietetic Challenges Ward Based Care Post Acute Injury – Dietetic Challenges Energy Requirements - Expenditure during this phase is unknown and hyper-metabolism can persist Patient A Week 1 67.6kg Week 2 68.4kg Week 3 67.0kg Week 4 68.8kg Week 5 66.3kg Week 6 66.1kg Week 7 61.8kg ? anomaly Week 8 65.8kg - Basal metabolic rate estimated 1527 - Fed 3,200kcals – (48kcals/kg )47% above BMR Patient B Week 1 46.7kg ? anomaly Week 2 51.1kg Week 3 50.8kg Week 4 50.9kg Week 5 49.6kg Week 6 48.4kg Week 7 47.8kg Week 8 47.2kg - Basal metabolic rate estimated 1446kcals - Fed 2880kcals (61kcals/kg) – 50% above BMR Post Acute Injury – Dietetic Challenges Autonomic Storming - Excessive uncontrolled activation of sympathetic nervous system characterised by - Excessive sweating Hypertension Tachypnoea Tachycardia Posturing - Increase Energy Expenditure young males can require in excess of 3,000kcals/day to maintain weight - Weekly monitoring of weight is essential to determine whether nutritional requirements are being met Post Acute Injury – Dietetic Challenges Monitoring - Obtain accurate body weight - Liaise with family members regarding weight history - Plan and agree realistic goals for weight, e.g. gain, maintenance or weight loss as appropriate Post-acute injury – Dietetic Challenges Fluid and Sodium Disturbances Syndrome of inappropriate diuretic hormone secretion  Fluid restriction  high energy/low volume feed Diabetes Insipidus  intravenous glucose/water, desmopressin  additional fluids (flushes/IV) some cases low sodium feed if persistently raised Na. Cerebral Salt Wasting  intravenous saline replacement  medical management little change to nutrition Post Acute Injury – Dietetic Challenges Bowel Dysfunction - Neurogenic Bowel - Constipation Diarrhoea Urgency Incontinence - Consider fibre content of feeds - Adequate hydration - Bowel management plans Post Acute Injury – Considerations Long-term enteral feeding - Considered > 4weeks after Nasogastric feeding Discussion with MDT, Family, Carers Facilitation of movement to rehabilitation RCP guidelines (2013) – Enteral nutrition and hydration via gastrostomy or jejunostomy with adequate nutritional support to meet dietary requirements. Including hypercatabolic state Post Acute Injury – Dietetic Challenges Nutrition and Dietetic Care Process (British Dietetic Association, 2009) Rehabilitation – Dietetic Challenges Rehabilitation – Dietetic Challenges - Many patients enter the rehabilitation phase in a malnourished state - Average weight loss during ITU 11 ± 6kg in 38days (Crenn et al., 2014) Severe malnutrition (body mass index of <15kg/m2) in brain injury has been shown to: - increase length of rehabilitation stay - contribute to more serious complications such as pressure ulcers, pneumonia, urinary tract infections (Denes, 2004) Rehabilitation – Dietetic Challenges Energy Requirements - Changes in metabolic demand - Patients who previously required 3000kcals may now gain weight on 1000kcals - Requires ongoing monitoring and adjustment Fig. 1. Time course of body mass index in 107 adult traumatic brain injured patients. P+: weight gain group, Pweight loss group, P= weight stabilization group, T1: before traumatic brain injury, T2: end of intensive care, T3: discharge from rehabilitation, T4: end of follow-up, BMI body mass index. (Crenn et al., 2014) Summary - Nutrition support in disorders of consciousness plays a vital role through all three phases of the patient journey form acute admission to rehabilitation. - Several challenges associated with nutrition in brain injury - dietetic assessment monitoring and evaluation is essential. Questions References British Dietetic Association (2009). Nutrition and Dietetic Care Process. Available from http://www.google.co.uk/url?sa=t&rct=j&q=&esrc=s&frm=1&source=web&cd=1&ved=0CCYQFjAA&url=http%3A %2F%2Fwww.rgu.ac.uk%2F979ED290-7EB7-11E3-8B2A0050568D00BF&ei=JveWU7GALLCM7AbkYD4Cg&usg=AFQjCNGbTPa8eJKVXLi4VCiLyeKb18QACA&bvm=bv.68445247,d.ZGU Borzotta AP, Pennings J, Papsadero B, et al. Enteral versus parenteral nutrition after severe closed head injury. J Trauma. 1994;37:459-468. Cook, A. M., Peppard, A and Magnuson, B. (2008). Nutrition considerations in traumatic brain injury. Nutrition in Clinical Practise. 23(6), 608-620 Crenn, P., Hamchaoui, S., Bourget-Massari, A., Hanachi, M., Melchoir, Jean-Claude and Azouvi, P. (2014). Changes in weight after traumatic brain injury in adult patients: A longitudinal study. Clinical Nutrition, 33, 348-353 Denes, Z (2004). Influence of severe malnutrition on rehabilitation in patients with severe head injury. Disability and Rehabilitation, 26(19), 1163-1165 DeLegge, M. H. (2011) Managing gastric residual volumes in the critically ill patient: an update. Current opinion in clinical nutrition and critical care. 14, 193-196 Dickerson, R. N., Mitchell, J. N, Morgan, L. M, Maish, G. O, Croce, M. A., Minard, G., and Brown, R. O. (2009) Disparate repsponse to metaclopramide therapy for gastric feeding intolerance in trauma patients with and without traumatic brain injury. Journal of Parenteral and Enteral Nutritoin, 33(6), 646-65 Hartl., R., Gerber, L. M., Ni, Q and Ghajar, J. (2008) Effect of early nutrition on deaths due to severe traumatic brain in jury. Jounral of Neurosurgery, 109, 50-56 References Kao, C. H., Chang Lai, S. P., Chieng, P. U., Yen, T. C. Gastric emptying in head injured patients. American Journal of Gastroenterology, 93 1108-1112 Klein, C. J., Stanek, G. S and Wiles, C. E. (1998). Overfeeding macronutrients to critically ill adults: Metabolic complications. Journal of the American Dietetic Association, 98, 795-806 Kreyman, K. G., Berger, M. M., Deutz, N. E. P., Hiesmayr M et al., (2006). ESPEN Guidelines on Enteral Nutrition: Intensive Care. Clinical Nutrition, 25, 210-223 McClave, S. A., Martinadle, V. W. Mccarthy , M., Roberts, P et al., (2009). Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient. Journal of Parenteral and Enteral Nutrition, 33(3), 277-316 Perel, P., Yanagawa, T., Bunn, F., Roberts, I., Wentz, R and Pierro, A (2006). Nutritional support for head-injured patients. Cochrange Database Systematic Reviews. 18(4) Royal College of Physicians (2013). Prolonged Disorders of Conciousness. National Clinical Guidelines. London RCP. Taylor S. J., Fettes S. B., Jewkes C, and Nelson R. J. (1999). Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Critical care Medicine 27, 2525-2531. Thomas and Bishop (2007) Manual of dietetic practise. 4th Edition. Wiley-Blackwell. P. 808