Nutrition
Causes of Acute Phase Nutrition Problems
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- Hypermetabolism, which may persist 4 - 6 weeks and be sustained throughout the injury:
- Rapidly erodes nutritional stores, particularly protein, resulting in rapid loss in lean body mass and immunosuppression and in nitrogen death
- Results in increased:
- Cortisol, glucagon, catecholamines, and cellular products in the blood, urine, and CSF
- Oxygen consumption, CO2 production, serum fibrinogen, C-reactive protein, and lactic acid
- Urinary zinc, urinary calcium, and blood calcium
- Results in decreased:
- Serum albumin, thyroxine-binding protein, and thyroxine retinol-binding prealbumin
- Serum zinc
- Results in altered fluid balance, electrolytes, and amino acids in plasma
- Urinary nitrogen excretion, due to mobilization of amino acids from muscle to meet the demand for increased protein, results in increased protein synthesis and a large increase in protein catabolism.
- Dysphagia can present as a delayed or absent swallowing reflex, reduced lingual control, prolonged oral transit time, reduced pharyngeal peristalsis, or laryngeal incompetence. Together with patients being easily distracted, dysphagia can result in gradual nutritional deterioration and eventually a starvation state or death if not treated
- Delayed gastric emptying causes problems with intragastric feeding, such as a nasogastric or gastrostomy tube, resulting in reduced caloric delivery and a significant incidence of aspiration pneumonia
- Medications to reduce ICP can cause specific nutritional deficits, e.g.:
- Mannitol, an osmotic diuretic, draws fluid from the brain and can cause severe electrolyte disturbances
- Pentobarbital, administered if initial therapy is inadequate, can decrease gastrointestinal motility and promote large gastric residuals in patients fed enterally. This is circumvented by placing nasojejunal tubes endoscopically. Conversely, barbiturates can reduce nitrogen excretion in TBI patients by 40%, improve nitrogen balance, and reduce energy expenditure up to 86% of predicted basal value
Based on information in Matarese LE and Gottschlich MM. Contemporary Nutrition Support Practice; A Clinical Guide. Philadelphia: Saunders, 1998; Mahan LK and Escott-Stump S. Krause's Food, Nutrition, & Diet Therapy, 9th ed. Philadelphia: Saunders, 1996; and Rombeau JL and Rolandelli RH, eds. Enteral and Tube Feeding, 3rd ed. Philadelphia: Saunders, 1997, except for information where other papers are cited.
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