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Effect of Early Enteral Nutrition on Outcome in Severely Head Injured Patients A Prospective Controlled Study Yamini Tiwar...
BACKGROUND <ul><li>Daily Caloric requirements in severe HI= severe burns </li></ul><ul><li>Has been estimated to range fro...
BACKGROUND Trauma Systemic Inflammatory Response INFECTION (Sepsis, Pneumonia, Meningitis) Unregulated Hypermetabolism Mul...
PATHOGENESIS Ott L, McClain CJ, Gillespie M, et al. Cytokines and metabolic dysfunction after severe head injury. J Neurot...
CURRENT STATUS <ul><li>Seven trials have studied the effect of nutrient administration on outcome in severe HI </li></ul><...
INDIAN SCENARIO <ul><li>No comparable Indian studies. </li></ul><ul><li>Adult pts are kept NPO for a variable period (3 da...
AIMS & OBJECTIVES <ul><li>To study and compare outcomes following early  and adequate  enteral feeding vis-à-vis late init...
STUDY DESIGN <ul><li>Prospective controlled study </li></ul><ul><li>5 month period </li></ul>
MATERIALS & METHODS <ul><li>INCLUSION CRITERIA </li></ul><ul><li>Patients with severe HI (GCS ≤ 8) </li></ul><ul><li>Durat...
MATERIALS & METHODS <ul><li>TEST GROUP </li></ul><ul><li>Pts had enteral feeding (through Ryles tube) started within 48 ho...
MATERIALS & METHODS <ul><li>CONTROL GROUP </li></ul><ul><li>Enteral feeding started in a delayed manner, based on currentl...
MATERIALS & METHODS <ul><li>OUTCOME ASSESSMENT </li></ul><ul><li>Outcome was assessed using Glasgow outcome score (GOS) at...
MATERIALS & METHODS <ul><li>Pts were enrolled into a control or a test group, depending upon the call-day. </li></ul>
RESULTS <ul><li>Total Recruitment </li></ul><ul><li>Test Group  17 pts </li></ul><ul><li>Control Group 20 pts </li></ul>
RESULTS <ul><li>Mean admission GCS </li></ul><ul><li>Test group 5.8 (range 3-8) </li></ul><ul><li>Control grp 5.2 (range 3...
RESULTS <ul><li>Surgical Intervention </li></ul><ul><li>Test Group 14 pts (82.3%) </li></ul><ul><li>Control Grp 18 pts (85...
RESULTS <ul><li>Time to Enteral feeding (From Injury) </li></ul><ul><li>Test Group 40 hrs   (range 12-48 hrs) </li></ul><u...
OUTCOME (GOS)
RESULTS (OUTCOME) <ul><li>Poor Outcome  (GOS 1-3) </li></ul><ul><li>Test Group 61.1% (n=11) </li></ul><ul><li>Control grou...
RESULTS <ul><li>Good Outcome   (GOS 4 & 5) </li></ul><ul><li>Test Group 35.3% (n=6) </li></ul><ul><li>Control grp 0%  (n=0...
CONCLUSIONS <ul><li>This study shows that early and appropriate nutritional support can play a pivotal role in improving o...
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Role of early enteral nutrition in severe head injury

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Role of early enteral nutrition in severe head injury

  1. 1. Effect of Early Enteral Nutrition on Outcome in Severely Head Injured Patients A Prospective Controlled Study Yamini Tiwari, Deepak Agrawal Department of Dietetics and *Neurosurgery Neurosciences centre, All India Institute of Medical Sciences, New Delhi
  2. 2. BACKGROUND <ul><li>Daily Caloric requirements in severe HI= severe burns </li></ul><ul><li>Has been estimated to range from 150-250% of RME </li></ul><ul><li>Protein requirements have been estimated at 1.5-2.0g/Kg/day </li></ul><ul><li>Clifton GL, Robertson CS, Choi SC. Assessment of nutritional requirements of head injured patients. J Neurosurg 1986;64:895-901. </li></ul>
  3. 3. BACKGROUND Trauma Systemic Inflammatory Response INFECTION (Sepsis, Pneumonia, Meningitis) Unregulated Hypermetabolism Multiple Organ Failure Protein Calorie Malnutrition
  4. 4. PATHOGENESIS Ott L, McClain CJ, Gillespie M, et al. Cytokines and metabolic dysfunction after severe head injury. J Neurotrauma. 1994;11:447-72. Starts on Day 1
  5. 5. CURRENT STATUS <ul><li>Seven trials have studied the effect of nutrient administration on outcome in severe HI </li></ul><ul><li>Most studies have compared parentral with enteral feeding </li></ul><ul><li>Cochrane review concluded that although early nutrition results in better outcome, further trials are needed </li></ul><ul><li>Yanagawa T, Bunn F, Roberts I, Wentz R, Pierro A. Nutritional support for head-injured patients. Cochrane Database Syst Rev. 2002 ;(3):CD001530. </li></ul>
  6. 6. INDIAN SCENARIO <ul><li>No comparable Indian studies. </li></ul><ul><li>Adult pts are kept NPO for a variable period (3 days to 2 weeks) </li></ul><ul><li>Usually on 2.5L of DNS/day (500Kcal) </li></ul><ul><li>Attempts to calculate caloric or protein requirements for individual pts lacking </li></ul><ul><li>Standard feed of 2500 Kcal / 50g Protein is given in adult patients </li></ul>
  7. 7. AIMS & OBJECTIVES <ul><li>To study and compare outcomes following early and adequate enteral feeding vis-à-vis late initiation of feeding in patients with severe head injuries </li></ul>
  8. 8. STUDY DESIGN <ul><li>Prospective controlled study </li></ul><ul><li>5 month period </li></ul>
  9. 9. MATERIALS & METHODS <ul><li>INCLUSION CRITERIA </li></ul><ul><li>Patients with severe HI (GCS ≤ 8) </li></ul><ul><li>Duration from injury <12 hours </li></ul><ul><li>EXCLUSION CRITERIA </li></ul><ul><li>Polytrauma (except long bone #) </li></ul><ul><li>Pts who died within 48 hrs of injury </li></ul>
  10. 10. MATERIALS & METHODS <ul><li>TEST GROUP </li></ul><ul><li>Pts had enteral feeding (through Ryles tube) started within 48 hours of injury </li></ul><ul><li>caloric requirements were calculated using the Harris-Benedict formula. </li></ul><ul><li>Kcal/day= BMR X Activity factor (2 in severe HI) </li></ul><ul><li>Men: BMR = 66 + (13.7 X wt in kg) + (5 X ht in cm) - (6.8 X age in years) </li></ul><ul><li>Protein intake at 1.8g/kg/day </li></ul>
  11. 11. MATERIALS & METHODS <ul><li>CONTROL GROUP </li></ul><ul><li>Enteral feeding started in a delayed manner, based on currently prevailing practices and decisions of the treating neurosurgeons </li></ul>
  12. 12. MATERIALS & METHODS <ul><li>OUTCOME ASSESSMENT </li></ul><ul><li>Outcome was assessed using Glasgow outcome score (GOS) at 4 weeks post-injury or death, whichever came earlier. </li></ul><ul><li>Good outcome :GOS 4-5 </li></ul><ul><li>Poor outcome : GOS 1-3 </li></ul><ul><li>Jennett B, Bond M. Assessment of outcome after severe brain damage. Lancet 1975;1(7905):480-4 </li></ul>Good recovery 5 Moderate disability 4 severe disability 3 Vegetative 2 Death 1 GOS
  13. 13. MATERIALS & METHODS <ul><li>Pts were enrolled into a control or a test group, depending upon the call-day. </li></ul>
  14. 14. RESULTS <ul><li>Total Recruitment </li></ul><ul><li>Test Group 17 pts </li></ul><ul><li>Control Group 20 pts </li></ul>
  15. 15. RESULTS <ul><li>Mean admission GCS </li></ul><ul><li>Test group 5.8 (range 3-8) </li></ul><ul><li>Control grp 5.2 (range 3-8) </li></ul>
  16. 16. RESULTS <ul><li>Surgical Intervention </li></ul><ul><li>Test Group 14 pts (82.3%) </li></ul><ul><li>Control Grp 18 pts (85%) </li></ul>
  17. 17. RESULTS <ul><li>Time to Enteral feeding (From Injury) </li></ul><ul><li>Test Group 40 hrs (range 12-48 hrs) </li></ul><ul><li>Control Group 7.1 days (range 48-336 hrs) </li></ul>
  18. 18. OUTCOME (GOS)
  19. 19. RESULTS (OUTCOME) <ul><li>Poor Outcome (GOS 1-3) </li></ul><ul><li>Test Group 61.1% (n=11) </li></ul><ul><li>Control group 100% (n=20) </li></ul><ul><li>(p=0.005) </li></ul>
  20. 20. RESULTS <ul><li>Good Outcome (GOS 4 & 5) </li></ul><ul><li>Test Group 35.3% (n=6) </li></ul><ul><li>Control grp 0% (n=0) </li></ul>
  21. 21. CONCLUSIONS <ul><li>This study shows that early and appropriate nutritional support can play a pivotal role in improving outcome in severely head injured patients. </li></ul><ul><li>Early nutrition support may be improving outcome by: decreasing infection (Pneumonia/meningitis/septicemia) & Preventing MOF </li></ul>
  22. 22. THANK YOU

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