Clinician-scientists from NewYork-Presbyterian Hospital/Weill Cornell Medical Center are suggesting an immediate and important change to guidelines used in the care of patients with traumatic brain injury (TBI). The researchers say that following TBI, patients should be given nutritional supplementation through a gastric feeding tube as soon as possible, which they say can improve their chances of survival by as much as four-fold.
The evidence shows that the body heals better when it is given proper nutrition, not just the bare minimum that keeps someone alive," says lead author Dr. Roger Härtl, a noted neurological surgeon at NewYork-Presbyterian/Weill Cornell, and the Leonard and Fleur Harlan Clinical Scholar and assistant professor of neurological surgery at Weill Cornell Medical College. "Before now, patients were required to have nutritional supplementation within the first week following their injury, but our findings suggest that this is simply not soon enough."
The study's findings are published in this month's issue of the Journal of Neurosurgery.
This is the largest study to ever look at the issue of nutrition and survival following TBI. The research team followed survival outcome and nutritional care in 797 patients from 2000–2006.
"The past recommendations were based only on common clinical observations and a very small study of only about 60 patients," says Dr. Härtl. "These new recommendations will be added to a widely used TBI handbook, 'Guidelines for Management of Severe Traumatic Brain Injury,'" published by the Brain Trauma Foundation.
To formulate their findings, the research team recorded the length of time it took for each patient to receive gastric nutrition and how many calories they ingested. After controlling for factors like age, high blood pressure, brain pressure, prior neurological and cardiac conditions, and CT scan results shortly after the time of injury, the researchers found that the earlier each patient received a feeding-tube, and the more calories they ingested, the better their likelihood for survival.
Without gastric feeding within the first 5-7 days of suffering their injury, patients had a two- and four-fold higher likelihood of death, respectively. Also, the study reports that every 10kcal/kg decrease in caloric intake was associated with a 30–40 percent increase in mortality rate.
The best outcomes for patients with TBI were observed when patients received a minimum of 25kcal/kg each day. Alarmingly, the researchers found that as many as 62 percent of the patients studied never met this level of caloric intake.
"I think these findings say a lot about using what we know from basic research and applying the knowledge directly to the care we give to patients," says Dr. Härtl. "For a long time, clinicians thought that intravenous fluids were enough -- based on anecdotal situations and some basic biochemical knowledge -- but now we know that this level of care is not meeting the actual requirement the body needs to repair itself following extreme trauma."
Co-authors of the study include Drs. Jam Ghajar, Linda Gerber and Quanhong Ni -- all of NewYork-Presbyterian/Weill Cornell and Weill Cornell Medical College.
NewYork-Presbyterian Hospital/Weill Cornell Medical Center, located in New York City, is one of the leading academic medical centers in the world, comprising the teaching hospital NewYork-Presbyterian and Weill Cornell Medical College, the medical school of Cornell University. NewYork-Presbyterian/Weill Cornell provides state-of-the-art inpatient, ambulatory and preventive care in all areas of medicine, and is committed to excellence in patient care, education, research and community service. Weill Cornell physician-scientists have been responsible for many medical advances -- from the development of the Pap test for cervical cancer to the synthesis of penicillin, the first successful embryo-biopsy pregnancy and birth in the U.S., the first clinical trial for gene therapy for Parkinson's disease, the first indication of bone marrow's critical role in tumor growth, and, most recently, the world's first successful use of deep brain stimulation to treat a minimally-conscious brain-injured patient. NewYork-Presbyterian, which is ranked sixth on the U.S.News & World Report list of top hospitals, also comprises NewYork-Presbyterian Hospital/Columbia University Medical Center, Morgan Stanley Children's Hospital of NewYork-Presbyterian, NewYork-Presbyterian Hospital/Westchester Division and NewYork-Presbyterian Hospital/The Allen Pavilion. Weill Cornell Medical College is the first U.S. medical college to offer a medical degree oversees and maintains a strong global presence in Austria, Brazil, Haiti, Tanzania, Turkey and Qatar. For more information, visit www.nyp.org and www.med.cornell.edu.
OBJECT: Traumatic brain injury (TBI) remains a serious public health crisis requiring continuous improvement in pre-hospital and inhospital care. This condition results in a hypermetabolic state that increases systemic and cerebral energy requirements, but achieving adequate nutrition to meet this demand has not been a priority in reducing death due to TBI. The effect of timing and quantity of nutrition on death within the first 2 weeks of injury was analyzed in a large prospective database of adult patients with severe TBI in New York State. METHODS: The study is based on 797 patients with severe TBI (Glasgow Coma Scale [GCS] score < 9) treated at 22 trauma centers enrolled in a New York State quality improvement program between 2000 and 2006. The inhospital section of the prospectively collected database includes information on age, initial GCS score, weight and height, results of CT scanning, and daily parameters such as pupillary status, arterial hypotension, GCS score, and number of calories fed per day. RESULTS: Patients who were not fed within 5 and 7 days after TBI had a 2- and 4-fold increased likelihood of death, respectively. The amount of nutrition in the first 5 days was related to death; every 10-kcal/kg decrease in caloric intake was associated with a 30-40% increase in mortality rates. This held up even after controlling for factors known to affect mortality, including arterial hypotension, age, pupillary status, initial GCS score, and CT scan findings. CONCLUSIONS: Nutrition is a significant predictor of death due to TBI. Together with prevention of arterial hypotension, hypoxia, and intracranial hypertension it is one of the few therapeutic interventions that can directly affect TBI outcome.
Härtl R, Gerber LM, Ni Q, Ghajar J. Effect of early nutrition on deaths due to severe traumatic brain injury. J Neurosurg. 2008 Jul;109(1):50-6. PMID: 18590432