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Energy balance and metabolism after severe traumatic brain injury: A pilot study using doubly labelled water
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Neuroscience, Rehabilitation Medicine.
Department of Clinical Nutrition, Sahlgrenska Academy at the University of Gothenburg and Sahlgrenska University Hospital, Gothenburg.
Department of Clinical Neuroscience, Section for Neurosurgery, Karolinska University Hospital Solna, Stockholm.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
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(English)Manuscript (preprint) (Other academic)
Abstract [en]

Objective: To explore the course of energy balance in patients with severe traumatic brain injury, from time of injury until twelve weeks post injury.

Method: This prospective desriptive study included six patients with isolated, closed severe traumatic brain injury and an expected hospital stay of ≥2-3 months. Energy balance was calculated from energy intake compared to total energy expenditure measured by continuous indirect calorimetry and doubly labelled water. Clinical and laboratory variables with possible influence on metabolism and nutritional delivery were recorded simultaneously. Intermittent indirect calorimetry measurements were used to differentiate components of the energy expended.

Results: Patients were roughly in energy balance while on mechanical ventilation, but in negative energy balance from the 3rd week post injury. The total energy expenditure then increased while the daily energy intake declined. Concurrent with this period were difficulties in retaining enteral and/or parenteral nutrition delivery routes until oral feeding was satisfactory. Nitrogen balance was back to normal at about 1.5 months and the inflammatory period with increased C-reactive protein levels continued for 12 to 58 days from time of injury. During the first and second month post injury, patients lost 8-19% of their initial body weight.

Conclusion: Data suggests that negative energy balance after a severe TBI could not only be explained by the elevated metabolic rate and catabolism induced by the trauma, but also by difficulties in securing alternative nutritional routes in the distressed patient.

Keyword [en]
Enegy balance, Metabolism, Traumatic brain injury, Doubly labelled water, Indirect calorimetry, Energy intake
National Category
Nutrition and Dietetics Anesthesiology and Intensive Care Surgery Nursing
Research subject
Nutrition; Caring Sciences in Medical Sciences; Rehabilitation Medicine
Identifiers
URN: urn:nbn:se:uu:diva-114122OAI: oai:DiVA.org:uu-114122DiVA: diva2:293084
Available from: 2010-02-10 Created: 2010-02-10 Last updated: 2010-02-10
In thesis
1. Energy Balance out of Balance after Severe Traumatic Brain Injury
Open this publication in new window or tab >>Energy Balance out of Balance after Severe Traumatic Brain Injury
2010 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The overall aim of the research presented here was to expand the knowledge on metabolic course and nutritional outcome in patients with severe traumatic brain injury and to analyze the use and accuracy of different methods of assessment.

Study I, a systematic review of 30 articles demonstrated consistent data on increased metabolic rate, of catabolism and of upper gastrointestinal intolerance in the majority of the patients during early post injury period. Data also indicated a tendency of less morbidity and mortality in early fed patients.

Study II, a retrospective survey, based on medical records of 64 patients from three regions in Sweden, showed that the majority of patients regained their independence in eating within six months post injury. However, energy intake was set at a low level and 68 % of the patients developed malnutrition with 10 to 29 % loss of initial body mass during the first and second month post injury.

Study III, a questionnaire based study addressed to 74 care units caring for patients with severe traumatic brain injury showed that resources in terms of qualified staff members were reportedly good, but nutritional guidelines were adopted in less than half of the units, screening for malnutrition at admission was rarely performed and surveillance of energy intake declined when oral intake began. Moreover, assessment of energy requirements relied on calculations and the profession in charge to estimate energy requirement varied depending on nutritional route and unit speciality. At transferral between units nutritional information was lost.

Study IV and V, a prospective descriptive study on metabolic course, energy balance and methods of assessment in six patients showed that patients were in negative energy balance from 3rd week post injury and lost 8-19 % of their initial body weight. Concurrent nutritional problems were difficulties in retaining enteral and/or parenteral nutrition delivery routes until oral feeding was considered satisfactory. The majority of methods for predicting energy expenditure agreed poorly with measured energy expenditure.  The Penn-State equation from 1998 was the only valid predictive method during mechanical ventilation.

This thesis concludes that patients with moderate or severe traumatic brain injury exhibit a wide range of increased metabolic rate, catabolism and upper gastrointestinal intolerance during the early post-injury period. Most patients regain independence in eating, but develop malnutrition. Suggested explanations, other than the systemic disturbances early post injury, could be the use of inaccurate predictions of energy expenditure, deficient nutritional routines and difficulties in securing alternative nutritional routes until oral feeding is satisfactory. The impact of timing, content and ways of administration of nutritional support on neurological outcome after a severe traumatic brain injury remains to be demonstrated.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2010. 74 p.
Series
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 523
Keyword
Energy expenditure, Traumatic brain injury, Metabolism, Nutrition
National Category
Nutrition and Dietetics Surgery Anesthesiology and Intensive Care Nursing
Research subject
Nutrition; Neurosurgery; Rehabilitation Medicine; Anaesthesiology and Intensive Care; Caring Sciences in Medical Sciences
Identifiers
urn:nbn:se:uu:diva-114130 (URN)978-91-554-7721-9 (ISBN)
Public defence
2010-03-25, Robergsalen, A40, Akademiska sjukhuset, ingång 40, 5 tr., Uppsala, 13:00 (Swedish)
Opponent
Supervisors
Available from: 2010-03-04 Created: 2010-02-10 Last updated: 2010-03-04Bibliographically approved

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