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Table 5.11 Enteral Feeding for Nutritional Management Post ABI

Author Year

Country

Research Design

PEDro

Sample Size

 

Methods

 

Outcome

Meirelles and de-Aguilar-Nascimento (2011)

Brazil

RCT

PEDro=5

N=22

 

Population: TBI; Enteral Nutrition (EN) Group: Mean Age=31yr; Gender: Male=11, Female=1; Mean GCS Score=9. Total Parenteral Nutrition (TPN) Group: Mean Age=31yr; Gender: Male=9, Female=1; Mean GCS Score=9.

Intervention: Patients were randomized to receive either EN or TPN. Both groups received a 25-30 kcal/kg/day and 1.5 g/kg/day of protein. EN was administered via 8 or 10F oro- or naso-enteral feeding tube in gastric position with pump infusion. TPN was administered via central venous access. Patients assessed daily for 5 days.

Outcome Measures: Mortality, morbidity, Length of Stay (LOS) in ICU, days of mechanical ventilation, amount of calories and protein received/d, blood samples of glucose, albumin, urea, creatinine, C-Reactive Protein (CRP), urinary urea (N).

1.        No significant differences were found in morbidity and mean ICU LOS between the EN and TPN group.

2.        Although the amount of calories increased significantly (p<0.01) each day of the study, there was a progressive caloric deficit (p=0.001) in the two groups without any significant difference between them.

3.        Those in the TPN group received significantly more (p<0.006) nitrogen than the EN group.

4.        Despite the increased loss of nitrogen, all patients showed significant improvement (p=0.001) in the nitrogen balance as a result of nutritional therapy.

5.        Even though each nutritional therapy offered increasing quantities of nitrogen and calories, the TPN therapy delivered nitrogen more efficiently compared to the EN therapy.

Nataloni et al. (1999)

Italy

RCT

PEDro=4

N=45

 

Population: Head injury; Mean Age=28yr; Gender: Male=31, Female=14. Group A (n=15): Mean GCS Score=6. Group B (n=15): Mean GCS Score=6. Group C (n=15): Mean GCS Score=5.

Intervention: Patients were randomly administered one of the following feeding conditions: enteral (Group A), parenteral (Group B), or both enteral and parenteral (Group C). Those who participated were expected to stay in ICU for ≥3 days. Feeding began within 2 days of ICU admission and continued for the length of stay.

Outcome Measures: Serum pre-albumin, Retinol-Binding Protein (RBP), nitrogen balance. Assessments were made at baseline and after (day 3, 7 and 11).

1.       Nitrogen balance, which was negative for all groups, improved over the course of treatment; however, it only significantly improved in Group A by day 11 (p<0.0001).

2.       Pre-albumin and RBP significantly increased in Group A compared to both Group B (p<0.001) and Group C (p<0.01). Significant differences in the level of pre-albumin began at day 3 (p<0.01) while the differences in the level of RBP began at day 7 (p<0.01).

Borzotta et al. (1994)

USA

RCT

PEDro=4

N=49

 

Population: Closed Head Injury; Gender: Male=40, Female=9; Early Parenteral Nutrition (TPN) Group (n=21): Mean Age=28.9yr; Mean GCS Score=5.4. Enteral Feeding (ENT) Group (n=28): Mean Age=26.2yr; Mean GCS Score=5.2.

Intervention: Patients in the TPN group were treated with early parenteral nutrition which at day 5 began conversion to gastric feeding with tapering of TPN. The ENT group had enteral feeding through jejunal tubes. Assessments made daily for 10 days and weekly for 5wk thereafter.

Outcome Measures: Measured Energy Expenditure (MREE), nitrogen excretion, complications.

1.            No significant differences noted for nitrogen excretion or balance, energy expenditures, meeting nutritional goals, and frequency of infections.

2.            Patient complications such as hyperglycemia (p<0.05) and diarrhea (p<0.05) were more common among patients receiving TPN.

3.           Efficiency of feeding, measured by ratio of calories to MREE, showed an advantage for TPN at day 3, but none after.

4.           There were no differences in mortality at the end of follow-up.

Young et al. (1987)

USA

RCT

PEDro=5

N=96

 

Population: Severe Head Injury. Total Parenteral nutrition (TPN) Group: Mean Age=29.9 yr. Enteral feeding (EN) Group: Mean Age=33.8 yr.

Intervention: Patients were randomly assigned to receive either TPN or EN. TPN was initiated within 48 hr post-injury. EN was initiated when tolerated by patients. Study went from admission to day 18. Assessments made every 6 hr in the ICU, or 1x/day in the hospital ward.

Outcome Measures: Intracranial pressure (ICP), serum glucose levels.

1.           No significant differences were found between groups in peak daily ICP; ICP was >20 mmHG in 75% of the TPN patients and 73% of the EN patients.

2.           Standard therapy was ineffective in controlling elevated ICP in 36% of the TPN and in 38% of the EN group.

3.          There were no significant between-group differences in serum osmolality.

4.           For the first 12 days, the TPN group received more calories and protein than the EN group (p=0.0001).

5.          There was a significant day × nutrition group interaction (p<0.0001); serum glucose levels were higher in the TPN group for the first 13 days post injury than EN group who had increased mean serum glucose content after 13 days.

Hadley et al. (1986)

USA

RCT

PEDro=4

N=45

Population: TBI; Median Age=28yr; Gender: Male=40, Female=5; Mean GCS Score=5.8; Time Post Injury=6 hr.

Intervention: Patients were randomly assigned to receive either total parenteral nutrition (TPN; n=24) or enteral nutrition (NG; n=21). Patients received high nitrogen and calorie feedings for a 14 days period of the study to try to obtain a positive nitrogen and calorie balance. Nitrogen loss was measured every other day.

Outcome Measure: Urinary nitrogen levels.

1.          Patients who received TPN achieved significantly higher mean daily nitrogen intakes (p<0.01) and losses (p<0.001) compared to those who received NG.

2.         There was no significant between-group difference in nitrogen balance.

Rapp et al. (1983)

USA

RCT

PEDro=4

N=38

 

Population: Head injury; Standard Enteral Nutrition (SEN) Group (n=18): Mean Age=34.9yr; Mean GCS Score=7.2. Total Parenteral Nutrition (TPN) Group (n=20): Mean Age=29.2yr; Mean GCS Score=7.7.

Intervention: Patients were randomly assigned to either the SEN or TPN group. TPN therapy was initiated within 48 hr of admission. EN was given via nasogastric tubes and initiated when tolerated.

Outcome Measures: Nutritional status (serum albumin, nitrogen balance, and daily calorie and nitrogen intake).

1.        No baseline between-group differences with the exception of mean peak temperature during the first 24 hr of hospitalization; TPN group had a higher mean temperature than SEN group (38.6ºC versus 38.0oC; p=0.02).

2.        Within the 18 day period, 8 of the 18 patients died in the SEN group compared to 0 deaths in the TPN group (p<0.0001).

3.        The TPN group had a significantly greater mean intake in nitrogen/d then the SEN group (10.2 gm versus 4.0 gm; p=0.002); the overall nitrogen balance was also significantly different between groups (p=0.002).

Chapple et al. (2016)

Australia

Case Control

N=37

 

Population: TBI=37; Mean Age=45.3yr; Gender: Male=32, Female=5; Severity: Moderate=12, Severe=24.

Intervention: Nutrition was delivered Enterally (EN), Parenterally (PN), or orally. Protein intake and energy levels quantified during patients’ stay in the Intensive Care unit (ICU; 530 days) and once moved to ward-based care (982 days) for a total of 1512 days. Protein and nutrients consumed calculated by comparison of weight before and after each meal for 3 days/wk.

Outcome Measures: Dietitian clinical assessments via FoodWorks 8 (FW8) dietary analysis software.

1.        EN was administered to 34 patients while in ICU and 18 in the ward. No patients received PN during the study period.

2.        Thirty-two patients completed oral feeding at least once (mean=17.5 days), with 20 beginning in ICU and 12 in the ward.

3.        Less absolute energy (p=0.015) and protein (p=0.001) intake in ICU than the ward according to FW8.

4.        Patients met their absolute requirements for energy and protein 83% and 75% of the time, respectively.

5.        Larger difference in prescribed vs actual energy intake in the ward than ICU (p=0.039), with no significance for protein intake (p=0.278).

6.        More contribution from EN than oral for both energy (1778 versus 1259 kcal/d; p=0.488) and protein (88 versus 57 g/d; p=0.373), and those that exclusively were EN had smaller energy deficits than oral feeding (p=.016).

Fan et al. (2016) China PCT N=40  

Population: Mean Age=41.69yr; Gender: Male=62, Female=58.

Intervention: Patients were assigned to receive nutrition Enterally (EN), Parenterally (PN), or both (EN+PN), supported by nutritional therapies. Measures were taken at day 1 and day 20.

Outcome Measures: Nutritional status, complications, clinical outcomes.

1.        Total serum protein was significantly decreased in the PN group (p<0.01) compared to serum protein on day 1, whereas total serum protein was significantly increased in EN and EN+PN groups (p<0.01).

2.        The EN group had significantly higher rates of diarrhea (p<0.01) compared to the PN and EN+PN group.

3.        Stress ulcers were significantly higher in the PN group (p<0.01) than the other two groups.

4.        The EN group had significantly higher rates of aspirated pneumonia (p<0.01). The EN group had the lowest rates of pyemia (p<0.01).

5.        The EN+PN group had the lowest rates of hypoproteinemia (p<0.01) and intracranial infection (p<0.01).

Horn et al. (2015)

USA

PCT

N=1701

 

Population: TBI=1701; Enteral Nutrition (EN; n=451): Mean Age=38.5yr; Gender: Male=326, Female=125; Mean Time Post Injury=31.9 days; No EN (n=1250): Mean Age=47.1yr; Gender: Male=895, Female=355; Mean Time Post Injury=19.8 days.

Treatment: Patients admitted to an inpatient rehabilitation center post TBI were grouped into either EN (>1 days on EN) or no EN (<1 day or no days). Analysis of demographic and treatment data to determine the relationship between EN and patient outcomes.

Outcome Measures: Functional Independence Measure (FIM), Comprehensive Severity Index (CSI), chart reviews, weight loss, Length of Stay (LOS).

1.        Upon admission, high brain injury score on CSI, low FIM motor score, and having moderate-severe dysphagia were the strongest predictors of needing EN (p<0.001; c statistic=0.903).

2.        Patients that received EN at standard or high protein concentrations for >25% of their stay (mean=19 days) had significantly better FIM discharge scores (p<0.030).

3.        EN with a high protein formula for >25% of hospital stay was significantly associated with an almost two-pound weight gain from admission to discharge, while patients that did not receive EN lost two pounds (p=0.001).

Clifton et al. (1984)

USA

Case Series

N= 14

 

Population: Head Injury; Mean Age=27.8yr; Gender: Male=12, Female=2; GCS Score Range=3-8; Mean Time Post Injury=2 hr.

Intervention: The REE of enteral nutrition fed patients was measured by indirect calorimetry, over the first 9 days of onset (n=14), up to 28 days post injury (n=4).

Outcome Measures: Resting Energy Expenditure (REE).

1.        Mean values of REE ranged from 2135±374 Kcal on 1-3 days to 2504±582 Kcal on 7-9 days, which was not statistically significant.

2.        The mean REE ranged from 102%-170% of predicted values, over the 9 days of study.

3.        A single patient who received barbiturates had a REE lower than predicted (79%).

4.        Among patients who were non-sedated and non-paralyzed, REE was 138% of predicted values.

5.        There were no significant changes in REE over the 9 days and no associations were noted between GCS and REE.