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PRIMARY OBJECTIVE: To examine the evidence on the metabolic state and nutritional treatment of patients with moderate-to-severe traumatic brain injury (TBI). Research design: A systematic review of the literature. METHODS AND PROCEDURES: From 1547 citations, 232 articles were identified and retrieved for text screening. Thirty-six studies fulfilled the criteria and 30 were accepted for data extraction. MAIN OUTCOMES AND RESULTS: Variations in measurement methods and definitions of metabolic abnormalities hampered comparison of studies. However, consistent data demonstrated increased metabolic rate (96-160% of the predicted values), of hypercatabolism (-3 to -16 g N per day) and of upper gastrointestinal intolerance in the majority of the patients during the first 2 weeks after injury. Data also indicated a tendency towards less morbidity and mortality in early fed patients. CONCLUSIONS: The impact of timing, content and ways of administration of nutritional support on neurological outcome after TBI remains to be demonstrated.

Objective: This study explored current nutritional treatment policies and nutritional outcome in patients with severe traumatic brain injury. Methods: We performed a retrospective, structured survey of the medical records of 64 patients up to 6 months after injury or until the patients were independent in nutritional administration. Results: Enteral nutrition was administered to 86% of patients. Fourteen patients (22%) had a gastrostomy; after 6 months four were still in use. At 6 months, 92% of patients received all food orally and 84% had gained nutritional independence. Energy intake was equal to the calculated basal metabolic rate throughout the first month after injury and increased by 21% during the second month. Sixty-eight percent exhibited signs of malnourishment with weight losses of 10-29%. Conclusion: This study suggests that most patients with severe traumatic brain injury regain their nutritional independence within the first 6 months after injury, but also that most develop signs of malnutrition.

Objective: To describe the resources and routines for nutritional management until 6 months after severe traumatic brain injury. Methods: Data collection was performed by use of questionnaires to staff professionals at three regional neurosurgical intensive and 75 other care units and a retrospective survey of medical and nursing records from 64 patients treated at these units. Results: Resources in terms of qualified staff members were reportedly good, while nutritional guidelines were adopted in less than half of the units. Screening for malnutrition at admission was rarely performed and the nutritional data in medical and nursing records were incomplete, i.e. there was a lack of body weight measurements in more than one-third of the care unit episodes and of body height data in more than half of the patients and a declining surveillance of energy intake when patients changed from parenteral or enteral nutrition to oral intake. Assessment of energy requirements relied on calculations and the assignment of who was to estimate it varied depending on which nutritional route was used and also between unit specialities. Finally, information on energy requirement, weight development and body mass index was present in only 16%, 7% and in 2% of the transferrals. Conclusions: Despite good resources of qualified staff, the nutritional assessment routines were deficient, resulting in incomplete nutritional data and lost nutritional information.

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 3^rd 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.

Objective: The aim was to evaluate the accuracy of methods to predict energy expenditure (EE) in patients with severe traumatic brain injury (TBI).

Method: To this prospective descriptive study, a small cohort of patients (n6) with isolated, severe TBI and an expected hospital stay of ≥2-3 months were included. The EE was measured at two intervals: by continuous indirect calorimetry during mechanical ventilation and by doubly labelled water from 3^rd to 5^th week post injury. Different equations for prediction of EE and a portable monitor, the SenseWear Armband were compared to the measured EE.

Result: The majority of methods for predicting EE agreed poorly with the measured EE during indirect calorimetry period. A good agreement was found only with the three Penn-State equations, but two were biased according to Bland Altman analysis. The Penn-State equation from 1998 was the only valid predictive method, with a mean difference per day close to zero (+22 kcal), an excellent agreement (ICC 0.82) with 72% (n54/75) accurately assessed days (±10% of the measured EE) and with all patients within clinically acceptable levels, i.e. ±15% of the measured EE. During doubly labelled water period, observations were too few for any conclusive statement.

Conclusion: These data support use of the Penn-State equation from 1998 to estimate EE in patients with severe TBI while on mechanical ventilation.