• Neurotrauma patients often develop a hypermetabolic and catabolic state.
• Risks include:
  1. Energy and protein deficits
  2. Immunosuppression
  3. Poorer functional outcomes and increased mortality

• Enteral nutrition (EN) should be started within 24–48 hours of ICU admission.
• Delays beyond 72 hours are associated with:
  1. Higher infection rates
  2. Prolonged ICU stays
  3. Increased mortality

• First-line: Enteral nutrition via nasogastric or post-pyloric tube.
• Parenteral nutrition (PN):
  1. Consider only if EN is contraindicated or not tolerated
  2. Higher risk of overfeeding and metabolic complications

• Target: 25–30 kcal/kg/day
• Use indirect calorimetry if available to fine-tune energy delivery
• Avoid overfeeding, especially in the acute phase

• 1.5–2.0 g/kg/day
• Crucial for minimizing muscle wasting and supporting immune function

• Glycemic control: target blood glucose 140–180 mg/dL
• Fluid and electrolyte balance:
  1. Monitor closely in TBI due to risk of SIADH or cerebral salt-wasting
• Micronutrients:
  1. Zinc, selenium, vitamin D, omega-3 fatty acids: possible neuroprotective roles
• Immunonutrition:
  1. Still controversial in TBI; evidence remains inconclusive

• Daily:
  1. Glucose, electrolytes, fluid balance
• Weekly:
  1. Weight, serum proteins (e.g., prealbumin for trends)
  2. Muscle mass estimates if feasible

• Nutrition plans should be individualized based on:
  1. Neurological status
  2. Hemodynamic stability
  3. GI function and aspiration risk

* Type of Study: Narrative Review * Authors: Thomas et al. * Institution and City: University of Pennsylvania, Philadelphia, PA, USA * Journal: Neurosurgical Clinics of North America*, July 2025 * Purpose: To synthesize current clinical practices and considerations for fluid, electrolyte, and Nutritional Management in Critically Ill Neurotrauma Patients. * Conclusions: Isotonic saline remains the fluid of choice for resuscitation in TBI. Hypertonic saline is increasingly favored over mannitol for hyperosmolar therapy. Electrolyte imbalances are prevalent and necessitate close management. Nutritional optimization requires multidisciplinary coordination due to the elevated metabolic demands in TBI ¹⁾.

Critical Peer Review

1. Scientific Rigor & Methodology:

This narrative review lacks systematic methodology, which limits reproducibility and objectivity. There is no explicit discussion of inclusion/exclusion criteria for literature cited, nor a transparency framework for evaluating evidence quality. Future iterations would benefit from at least a semi-structured approach or alignment with PRISMA-ScR guidelines for scoping reviews.

2. Clinical Utility:

While the review offers a general overview, it fails to provide granular clinical algorithms or decision-support tools that could assist intensivists or neurosurgeons in real-time management. No risk stratification models or patient-specific recommendations (e.g., based on ICP levels or renal function) are offered.

3. Originality and Novelty:

The subject matter is not novel, and the article largely reiterates established guidelines without offering new interpretations or analyses. The preference for hypertonic saline over mannitol is now well-supported and widely practiced; reiterating it without new data or insights adds little scholarly value.

4. Evidence Support:

Claims are largely made without critical appraisal of the underlying studies. For instance, recommendations regarding fluid choice are asserted without reference to the quality, size, or outcomes of supporting trials. Furthermore, key controversies (e.g., timing and thresholds for nutritional interventions) are mentioned but not analyzed.

5. Writing and Structure:

The manuscript is readable but suffers from a lack of depth and precision. For example, “patients with especially traumatic brain injury” is an awkward and unclear phrase. More rigorous terminology and structured subheadings could enhance clarity and scientific tone.

6. Conflicts of Interest & Transparency:

The authors report no conflicts of interest, and affiliations are clearly stated.

Recommendation: Major Revision — This review requires significant enhancement in methodological transparency, clinical specificity, and scholarly depth. A restructured, evidence-graded format with inclusion of decision pathways or comparative tables would greatly improve its value to the neurosurgical critical care community.