1. Basics in Clinical
Nutrition: Nutritional
Support in Trauma
Laurance Genton, Jacques A. Romand, Claude Pichard
European Society for Clinical Nutrition and Metabolism
Reporter: Ri 翁贏雪
Supervisior: VS 韓吟宜

2. Pathophysiology of Trauma
 Definition: any physical damage to the body
 Mostly occurs in young patients
 Little or no protein-depletion

4. Wound Healing and Nutrition
 Wound healing depends on nutritional state
 Protein deficiency → new capillary formation,
fibroblastic proliferation, production of
proteoglycans, collagen synthesis↓→ delayed
wound healing
 Arginine
 Enhance wound healing and immune function
 Increase secretion of growth hormone
 Vitamin A, C, and E, and trace element (Zn, Cu, Se,
Mg)
 Fe
 Severe anemia reduce wound healing

5. Timing and Route of Feeding
 Early nutritional support (<72 hrs)
 Threefold decrease in sepsis
 Total enteral nutrition (TEN)
 Better ultilization of nutrients
 Prevent gut mucosa atrophy
 Preserve gut flora
 Reduce stress response
 Maintain immunocompetence

6. Timing and Route of Feeding
 Abdominal Trauma Index >15 with TEN
 Reduce septic complications from intra-abdominal
abscess and pneumonia
 Contraindication
 Full-blown shock
 Sepsis and incomplete resuscitation: reduced
splanchnic blood flow → non-occlusive bowel
necrosis

8. Energy Needs and Delivery
 Moderate trauma
 Non-protein: 25-30 Kcal/kg/day (NPC)
 Protein: 1.0-1.5 g/kg
 NPC: Nitrogen = 80-120
 Resolving stress
 NPC: the same
 Protein: 1.0-1.2 g/kg
 NPC: Nitrogen = 130-160

9. Energy Needs and Delivery
 Severe trauma (Abdominal Trauma Index
>20 or Injury Severity Score > 18) or less
severe trauma with complications
 Calorie needs: the same
 Protein: ↑
 Immune-enhancing diet (protein: 2.2-2.5 g/kg/day)
 fewer infections, less MOF, decreased use of antibiotics
and shorter length of hospital stay
 Continue for 7-10 days → standard diets
 Induce energy deficit in the long-term

10. Severe Head Trauma

11. Severe Head Trauma
 Energy expenditure
 135-165% of basal metabolic rate
 Increased catecholamine levels, hyperactivity of the
autonomic nervous system
 Highest during the three first days
 Brain death
 Energy expenditure: 70-80% of basal metabolic rate
 Protein breakdown
 Muscle wasting and lower levels of visceral proteins
(prealbumin, albumin, transferrin)
 Urinary nitrogen loss is high: 12-30 g/day
 At least 3 weeks after head injury

12. Severe Head Trauma
 Hyperglycemia
 Frequent during the first 24 hours
 Aggravate the preexisting ischemia: stimulating the
anaerobic metabolism → increasing intracellular lactate
and acidosis in brain tissue → neuronal damage
 Blood glucose > 110mg/dl → continuous infusion of insulin
 Tight control of blood glucose improves outcome
 Immune system alterations
 60% infection rate in brain-injured patients
 Nutrients, mineral or cytokine deficits → anergy to cell-
mediated immune response
 Low level of awakeness, cervical or laryngeal damages →
reduced vomiting reflex → aspiration peumonia

13. Severe Head Trauma
 Nutritional support
 Intracranial pressure and peripheral hemodynamics have
been stabilized
 Early nutrition: improve outcome and decrease infection
rate
 Enteral nutrition
 Contrastly, has little effect on infectious complications
 >48 hrs after admission → parenteral nutrition
 Gastrointestinal motility↓→ post-pyloric feeding

14. Severe Head Trauma
 Overfeeding
 Conversion of excess nutrients to glycogen or lipid
→ increases O2 consumption → increased CO2
production and dilation of brain arteries → IICP
 Decrease carbohydrate to lipid ratio
 Glucose oxidation: 30% more CO2 production
than lipid
 High lipid intake → immune dysfunction

15. Summary
 Trauma is characterized by combination of
cardiovascular, inflammatory and metabolic
responses
 TEN, early nutrition: reduce the incidence of
septic complications in trauma patients
 Immune-enhancing diet may be useful in
severely injured subjects
 In head-injured patients
 Control ICP
 Not overfeeding

16. Thanks for Your Attention