Caloric requirements for severe traumatic brain injury [Neurosurgery Wiki]

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====== Caloric requirements for severe traumatic brain injury ======
Several [[Cochrane]] [[review]]s have established a reasonable basis for early and adequate [[feeding]] following [[traumatic brain injury]] (TBI), although the number and size of the [[trial]]s supporting this [[recommendation]] are limited
((Perel P, Yanagawa T, Bunn F, Roberts I, Wentz R, Pierro A. Nutritional support for head-injured patients. Cochrane Database Syst Rev. 2006 Oct 18;2006(4):CD001530. doi: 10.1002/14651858.CD001530.pub2. PMID: 17054137; PMCID: PMC7025778.)).
((Yanagawa T, Bunn F, Roberts I, Wentz R, Pierro A. Nutritional support for head-injured patients. Cochrane Database Syst Rev. 2002;(3):CD001530. doi: 10.1002/14651858.CD001530. Update in: Cochrane Database Syst Rev. 2006;(4):CD001530. PMID: 12137627.)).


[[Nutrition]] is a significant predictor of [[death]] due to [[TBI]]. Together with the [[prevention]] of arterial [[hypotension]], [[hypoxia]], and [[intracranial hypertension]], it is one of the few therapeutic [[intervention]]s that can directly affect [[traumatic brain injury outcome]].
((Härtl R, Gerber LM, Ni Q, Ghajar J. Effect of early [[nutrition]] on [[death]]s due to [[severe traumatic brain injury]]. J Neurosurg. 2008 Jul;109(1):50-6. doi: 10.3171/JNS/2008/109/7/0050. PMID: 18590432.))


Although the calorie and protein intakes had increased from baseline, hospitalized TBI patients were still at a risk to develop [[malnutrition]] as the average intakes were considerably low as compared to their requirements. Optimum nutrient intakes especially calorie and protein are crucial to ensure optimum recovery process as well as to minimize risks of infection and complications
((Abdullah MI, Ahmad A, Syed Saadun Tarek Wafa SWW, Abdul Latif AZ, Mohd Yusoff NA, Jasmiad MK, Udin N, Abdul Karim K. Determination of calorie and protein intake among acute and sub-acute traumatic brain injury patients. Chin J Traumatol. 2020 Oct;23(5):290-294. doi: 10.1016/j.cjtee.2020.04.004. Epub 2020 Apr 24. PMID: 32423779; PMCID: PMC7567897.)).

With severe injury such as TBI, energy intakes in the range of 25–30 kcal/kg/day are generally recommended
((Cerra FB, Benitez MR, Blackburn GL, Irwin RS, Jeejeebhoy K, Katz DP, Pingleton SK, Pomposelli J, Rombeau JL, Shronts E, Wolfe RR, Zaloga GP. Applied nutrition in ICU patients. A consensus statement of the American College of Chest Physicians. Chest. 1997 Mar;111(3):769-78. doi: 10.1378/chest.111.3.769. PMID: 9118718.))
((McClave SA, Martindale RG, Vanek VW, McCarthy M, Roberts P, Taylor B, Ochoa JB, Napolitano L, Cresci G; A.S.P.E.N. Board of Directors; American College of Critical Care Medicine; Society of Critical Care Medicine. Guidelines for the Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and Enteral Nutrition (A.S.P.E.N.). JPEN J Parenter Enteral Nutr. 2009 May-Jun;33(3):277-316. doi: 10.1177/0148607109335234. PMID: 19398613.)).
[[Harris–Benedict equation]] values are similar at 22–24 kcal/kg, but their calculation includes the additional factors of [[height]], [[sex]], and [[age]].

[[Rest]]ed [[coma]]tose [[patient]]s with isolated [[head injury]] have a [[Basal Metabolic Rate]] that is 140% of normal for that patient (range: 120–250%)
((Clifton GL, Robertson CS, Grossman RG, et al. The
Metabolic Response to Severe Head Injury. J
Neurosurg. 1984; 60:687–696))
((Young B, Ott L, Norton J, et al. Metabolic and
Nutritional Sequelae in the Non-Steroid Treated Head
Injury Patient. Neurosurgery. 1985; 17:784–791))
((Deutschman CS, Konstantinides FN, Raup S, et al. Physiological and Metabolic Response to Isolated
Closed Head Injury. J Neurosurg. 1986; 64:89–98))
((Bullock R, Chesnut RM, Clifton G, et al. Guidelines
for the Management of Severe Head Injury. 1995))

[[Paralysis]] with [[neuromuscular blocker]] or [[barbiturate coma]] reduced this excess expenditure in most patients to ≈ 100–120% of normal, but some remained elevated by 20–30%.
((Clifton GL, Robertson CS, Choi SC. Assessment of Nutritional Requirements of Head Injured Patients.
J Neurosurg. 1986; 64:895–901)).
Energy requirements rise during the first 2 weeks after injury, but it is not known for how long this elevation persists. Mortality is reduced in patients who receive a full caloric replacement by day 7 after trauma
((Rapp RP, Young B, Twyman D, et al. The Favorable
Effect of Early Parenteral Feeding on Survival in Head Injured Patients. J Neurosurg. 1983; 58: 906–912))
(a beneficial effect with an earlier goal of replacement by 3 days post-trauma was not found
((Young B, Ott L, Twyman D, et al. The Effect of Nutritional Support on Outcome from Severe Head Injury. Neurosurgery. 1987; 67:668–676)).
Since it generally takes 2–3 days to get a nutritional replacement up to speed whether the enteral or parenteral route is utilized,
((Bullock R, Chesnut RM, Clifton G, et al. Guidelines
for the Management of Severe Head Injury. 1995)) 
it is recommended that nutritional supplementation begins within 72 hrs of head injury.

===== The Geriatric Nutritional Risk Index (GNRI) =====

The Geriatric Nutritional Risk Index (GNRI) is a simple and objective screening tool for clinicians to screen patients' [[nutritional status]] based on [[serum albumin]] level and their [[weight]] and [[height]]. The original study had divided patients based on GNRI into quartiles of nutritional risk for [[death]]: a no-risk group (GNRI >98), a low-risk group (GNRI 92-98), a moderate-risk group (GNRI 82 to <92), and a major-risk group (GNRI <82). 
It is a significant independent [[risk factor]] and a promising simple assessment tool for mortality in elderly patients with moderate to severe TBI
((Su WT, Tsai CH, Huang CY, Chou SE, Li C, Hsu SY, Hsieh CH. Geriatric Nutritional Risk Index as a Prognostic Factor for Mortality in Elderly Patients with Moderate to Severe Traumatic Brain Injuries. Risk Manag Healthc Policy. 2021 Jun 10;14:2465-2474. doi: 10.2147/RMHP.S314487. PMID: 34140818; PMCID: PMC8203299.)).