Nutritional support for patients sustaining traumatic brain injury: a systematic review and meta-analysis of prospective studies

Xiang Wang, Yan Dong, Xi Han, Xiang-Qian Qi, Cheng-Guang Huang, Li-Jun Hou, Xiang Wang, Yan Dong, Xi Han, Xiang-Qian Qi, Cheng-Guang Huang, Li-Jun Hou

Abstract

Background: In traumatic brain injury (TBI), the appropriate timing and route of feeding, and the efficacy of immune-enhancing formulae have not been well established. We performed this meta-analysis aiming to compare the effects of different nutritional support modalities on clinical outcomes of TBI patients.

Methods: We systematically searched Pubmed, Embase, and the Cochrane Library until October, 2012. All randomized controlled trials (RCTs) and non-randomized prospective studies (NPSs) that compared the effects of different routes, timings, or formulae of feeding on outcomes in TBI patients were selected. The primary outcomes included mortality and poor outcome. The secondary outcomes included the length of hospital stay, the length of ventilation days, and the rate of infectious or feeding-related complications.

Findings: 13 RCTs and 3 NPSs were included. The pooled data demonstrated that, compared with delayed feeding, early feeding was associated with a significant reduction in the rate of mortality (relative risk [RR] = 0.35; 95% CI, 0.24-0.50), poor outcome (RR = 0.70; 95% CI, 0.54-0.91), and infectious complications (RR = 0.77; 95% CI, 0.59-0.99). Compared with enteral nutrition, parenteral nutrition showed a slight trend of reduction in the rate of mortality (RR = 0.61; 95% CI, 0.34-1.09), poor outcome (RR = 0.73; 95% CI, 0.51-1.04), and infectious complications (RR = 0.89; 95% CI, 0.66-1.22), whereas without statistical significances. The immune-enhancing formula was associated with a significant reduction in infection rate compared with the standard formula (RR = 0.54; 95% CI, 0.35-0.82). Small-bowel feeding was found to be with a decreasing rate of pneumonia compared with nasogastric feeding (RR = 0.41; 95% CI, 0.22-0.76).

Conclusion: After TBI, early initiation of nutrition is recommended. It appears that parenteral nutrition is superior to enteral nutrition in improving outcomes. Our results lend support to the use of small-bowel feeding and immune-enhancing formulae in reducing infectious complications.

Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Figure 1. The flow diagram shows the…
Figure 1. The flow diagram shows the selection of studies for the meta-analysis.
Figure 2. Comparison of the effect of…
Figure 2. Comparison of the effect of early feeding and delayed feeding on outcomes in patients with TBI.
(A) Forest plot illustrates the different effects on mortality. (B) Forest plot shows the different effects on poor outcome. PO, poor outcome.
Figure 3. Comparison of the effect of…
Figure 3. Comparison of the effect of early feeding and delayed feeding on infectious complications in patients with TBI.
Figure 4. Funnel plots for the detection…
Figure 4. Funnel plots for the detection of publication bias.
(A) Funnel plot of studies evaluating the effects of feeding timings on mortality, which is approximately symmetric. (B) Funnel plot of studies evaluating the effects of feeding routes on mortality, which appears to be symmetric.
Figure 5. Comparison of the effect of…
Figure 5. Comparison of the effect of enteral feeding and parenteral feeding on outcomes in patients with TBI.
(A) Forest plot illustrates the different effect on mortality. (B) Forest plot shows the different effect on poor outcome. PO, poor outcome.
Figure 6. Comparison of the effect of…
Figure 6. Comparison of the effect of enteral feeding and parenteral feeding on infectious complications in patients with TBI.

References

    1. Giacino JT, Whyte J, Bagiella E, Kalmar K, Childs N, et al. (2012) Placebo-controlled trial of amantadine for severe traumatic brain injury. N Engl J Med 366: 819–826.
    1. Rosenfeld JV, Maas AI, Bragge P, Morganti-Kossmann MC, Manley GT, et al. (2012) Early management of severe traumatic brain injury. Lancet 380: 1088–1098.
    1. Cook AM, Peppard A, Magnuson B (2008) Nutrition considerations in traumatic brain injury. Nutr Clin Pract 23: 608–620.
    1. Vizzini A, Aranda-Michel J (2011) Nutritional support in head injury. Nutrition 27: 129–132.
    1. Gadisseux P, Ward JD, Young HF, Becker DP (1984) Nutrition and the neurosurgical patient. J Neurosurg 60: 219–232.
    1. Bistrian BR, Askew W, Erdman JW, Oria MP (2011) Nutrition and traumatic brain injury: a perspective from the Institute of Medicine report. JPEN J Parenter Enteral Nutr 35: 556–559.
    1. Casaer MP, Mesotten D, Hermans G, Wouters PJ, Schetz M, et al. (2011) Early versus late parenteral nutrition in critically ill adults. N Engl J Med 365: 506–517.
    1. Heidegger CP, Berger MM, Graf S, Zingg W, Darmon P, et al. (2013) Optimisation of energy provision with supplemental parenteral nutrition in critically ill patients: a randomised controlled clinical trial. Lancet 381: 385–393.
    1. Bratton SL, Chestnut RM, Ghajar J, McConnell Hammond FF, Harris OA, et al. (2007) Guidelines for the management of severe traumatic brain injury. XII. Nutrition. J Neurotrauma 24 Suppl 1S77–82.
    1. Moher D, Liberati A, Tetzlaff J, Altman DG (2009) Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. PLoS Med 6: e1000097.
    1. Jadad AR, Moore RA, Carroll D, Jenkinson C, Reynolds DJ, et al. (1996) Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials 17: 1–12.
    1. Wells GA, Shea B O, Connell D, Peterson JVW (2009) The Newcastle-Ottawa Scale (NOS) for assessing the quality of nonrandomised studies in meta-analyses. Available: epidemiology/oxfordhtm Accessed 9 May 2010.
    1. Higgins JPT, Green S, Collaboration C (2008) Cochrane handbook for systematic reviews of interventions: Wiley Online Library.
    1. Hausmann D, Mosebach KO, Caspari R, Rommelsheim K (1985) Combined enteral-parenteral nutrition versus total parenteral nutrition in brain-injured patients. A comparative study. Intensive Care Med 11: 80–84.
    1. Calon B, Pottecher T, Frey A, Ravanello J, Otteni JC, et al. (1990) Long-chain versus medium and long-chain triglyceride-based fat emulsion in parental nutrition of severe head trauma patients. Infusionstherapie 17: 246–248.
    1. Boselli M, Aquilani R, Baiardi P, Dioguardi FS, Guarnaschelli C, et al. (2012) Supplementation of essential amino acids may reduce the occurrence of infections in rehabilitation patients with brain injury. Nutrition in Clinical Practice 27: 99–113.
    1. Maurya I, Pawar M, Garg R, Kaur M, Sood R (2011) Comparison of respiratory quotient and resting energy expenditure in two regimens of enteral feeding - Continuous vs. intermittent in head-injured critically ill patients. Saudi Journal of Anaesthesia 5: 195–201.
    1. Taylor SJ, Fettes SB, Jewkes C, Nelson RJ (1999) Prospective, randomized, controlled trial to determine the effect of early enhanced enteral nutrition on clinical outcome in mechanically ventilated patients suffering head injury. Crit Care Med 27: 2525–2531.
    1. Clifton GL, Robertson CS, Contant CF (1985) Enteral hyperalimentation in head injury. Journal of Neurosurgery 62: 186–193.
    1. Twyman D, Young AB, Ott L, Norton JA, Bivins BA (1985) High protein enteral feedings: a means of achieving positive nitrogen balance in head injured patients. JPEN J Parenter Enteral Nutr 9: 679–684.
    1. Sacks GS, Brown RO, Teague D, Dickerson RN, Tolley EA, et al. (1995) Early nutrition support modifies immune function in patients sustaining severe head injury. JPEN J Parenter Enteral Nutr 19: 387–392.
    1. Suchner U, Senftleben U, Eckart T, Scholz MR, Beck K, et al. (1996) Enteral versus parenteral nutrition: effects on gastrointestinal function and metabolism. Nutrition 12: 13–22.
    1. Berg A, Bellander BM, Wanecek M, Norberg A, Ungerstedt U, et al. (2008) The pattern of amino acid exchange across the brain is unaffected by intravenous glutamine supplementation in head trauma patients. Clin Nutr 27: 816–821.
    1. Nataloni S, Gentili P, Marini B, Guidi A, Marconi P, et al. (1999) Nutritional assessment in head injured patients through the study of rapid turnover visceral proteins. Clin Nutr 18: 247–251.
    1. Young B, Ott L, Haack D, Twyman D, Combs D, et al. (1987) Effect of total parenteral nutrition upon intracranial pressure in severe head injury. J Neurosurg 67: 76–80.
    1. Rapp RP, Young B, Twyman D, Bivins BA, Haack D, et al. (1983) The favorable effect of early parenteral feeding on survival in head-injured patients. J Neurosurg 58: 906–912.
    1. Hadley MN, Grahm TW, Harrington T, Schiller WR, McDermott MK, et al. (1986) Nutritional support and neurotrauma: a critical review of early nutrition in forty-five acute head injury patients. Neurosurgery 19: 367–373.
    1. Young B, Ott L, Twyman D, Norton J, Rapp R, et al. (1987) The effect of nutritional support on outcome from severe head injury. J Neurosurg 67: 668–676.
    1. Grahm TW, Zadrozny DB, Harrington T (1989) The benefits of early jejunal hyperalimentation in the head-injured patient. Neurosurgery 25: 729–735.
    1. Borzotta AP, Pennings J, Papasadero B, Paxton J, Mardesic S, et al. (1994) Enteral versus parenteral nutrition after severe closed head injury. J Trauma 37: 459–468.
    1. Minard G, Kudsk KA, Melton S, Patton JH, Tolley EA (2000) Early versus delayed feeding with an immune-enhancing diet in patients with severe head injuries. JPEN J Parenter Enteral Nutr 24: 145–149.
    1. Falcao de Arruda IS, de Aguilar-Nascimento JE (2004) Benefits of early enteral nutrition with glutamine and probiotics in brain injury patients. Clin Sci (Lond) 106: 287–292.
    1. Kostadima E, Kaditis AG, Alexopoulos EI, Zakynthinos E, Sfyras D (2005) Early gastrostomy reduces the rate of ventilator-associated pneumonia in stroke or head injury patients. Eur Respir J 26: 106–111.
    1. Briassoulis G, Filippou O, Kanariou M, Papassotiriou I, Hatzis T (2006) Temporal nutritional and inflammatory changes in children with severe head injury fed a regular or an immune-enhancing diet: A randomized, controlled trial. Pediatr Crit Care Med 7: 56–62.
    1. Khorana J, Rerkasem K, Apichartpiyakul C, Sakonwasun C, Watcharasakslip W, et al. (2009) Immunonutrition and cytokine response in patients with head injury. J Med Assoc Thai 92: 188–194.
    1. Acosta-Escribano J, Fernandez-Vivas M, Grau Carmona T, Caturla-Such J, Garcia-Martinez M, et al. (2010) Gastric versus transpyloric feeding in severe traumatic brain injury: a prospective, randomized trial. Intensive Care Med 36: 1532–1539.
    1. Chourdakis M, Kraus MM, Tzellos T, Sardeli C, Peftoulidou M, et al. (2012) Effect of early compared with delayed enteral nutrition on endocrine function in patients with traumatic brain injury: an open-labeled randomized trial. JPEN J Parenter Enteral Nutr 36: 108–116.
    1. Justo Meirelles CM, de Aguilar-Nascimento JE (2011) Enteral or parenteral nutrition in traumatic brain injury: a prospective randomised trial. Nutr Hosp 26: 1120–1124.
    1. Hartl R, Gerber LM, Ni Q, Ghajar J (2008) Effect of early nutrition on deaths due to severe traumatic brain injury. J Neurosurg 109: 50–56.
    1. Chiang YH, Chao DP, Chu SF, Lin HW, Huang SY, et al. (2012) Early enteral nutrition and clinical outcomes of severe traumatic brain injury patients in acute stage: a multi-center cohort study. J Neurotrauma 29: 75–80.
    1. Dhandapani S, Dhandapani M, Agarwal M, Chutani AM, Subbiah V, et al. (2012) The prognostic significance of the timing of total enteral feeding in traumatic brain injury. Surg Neurol Int 3: 31.
    1. Perel P, Yanagawa T, Bunn F, Roberts I, Wentz R, et al... (2006) Nutritional support for head-injured patients. Cochrane Database Syst Rev: CD001530.
    1. Griffiths RD (2006) Parenteral nutrition in adults with a functional gastrointestinal tract. Lancet 368: 1868.
    1. Ziegler TR (2009) Parenteral nutrition in the critically ill patient. N Engl J Med 361: 1088–1097.
    1. Vincent JL, Preiser JC (2012) When should we add parenteral to enteral nutrition? Lancet 381: 354–355.
    1. Zaloga GP (2006) Parenteral nutrition in adult inpatients with functioning gastrointestinal tracts: assessment of outcomes. Lancet 367: 1101–1111.
    1. Kreymann KG, Berger MM, Deutz NE, Hiesmayr M, Jolliet P, et al. (2006) ESPEN Guidelines on Enteral Nutrition: Intensive care. Clin Nutr 25: 210–223.
    1. Worthington ML, Cresci G (2011) Immune-modulating formulas: who wins the meta-analysis race? Nutr Clin Pract 26: 650–655.
    1. Egger M, Davey Smith G, Schneider M, Minder C (1997) Bias in meta-analysis detected by a simple, graphical test. BMJ 315: 629–634.
    1. Krakau K, Omne-Ponten M, Karlsson T, Borg J (2006) Metabolism and nutrition in patients with moderate and severe traumatic brain injury: A systematic review. Brain Inj 20: 345–367.
    1. Foley N, Marshall S, Pikul J, Salter K, Teasell R (2008) Hypermetabolism following moderate to severe traumatic acute brain injury: a systematic review. J Neurotrauma 25: 1415–1431.

Source: PubMed

Patrocinadores y Colaboradores

Condiciones médicas

Intervenciones de drogas

3
Suscribir