Nutrition Support for Head-injured Patients

Abstract

Head injury increases the body's metabolic responses, and thus, nutritional demands. Provision of an adequate supply of nutrients is associated with improved outcome. The best route for administering nutrition [total parenteral nutrition (TPN) or enterally (EN)] and the best timing of administration (eg, early versus late) of nutrients needs to be established. To quantify the effect on mortality and morbidity of alternative strategies of providing nutrition support following head injury, trials were identified by computerized searches of the Injuries Group specialized register, Cochrane Controlled Trials Register, MEDLINE, EMBASE, and BIDS Index to Scientific and Technical Proceedings, and by checking the reference lists of trials and review articles. Randomized controlled trials of timing or route of nutrition support after acute traumatic brain injury were included in this review. Two reviewers independently abstracted data and assessed trial quality. Information was collected on death, disability, and incidence of infection. If trial quality was unclear or if there were missing outcome data, trialists were contacted in an attempt to get further information. Of the 7 trials addressing the timing of support, data on mortality were obtained for all 7 trials (284 participants). The relative risk (RR) for death with early nutrition support was 0.67 (95% confidence interval [CI], 0.41 to 1.07). Data on disability were available for 3 trials. The RR for death or disability at the end of follow-up was 0.75 (0.50 to 1.11). Seven trials compared parenteral versus enteral nutrition. Because early support often involves parenteral nutrition, 3 of the trials are also included in the previous analyses. Five trials (207 participants) reported mortality. The RR for mortality at the end of the follow-up period was 0.66 (0.41 to 1.07). Two trials provided data on death and disability. The RR was 0.69 (95% CI, 0.40 to 1.19). There was 1 trial with no deaths, and the RR was not estimable. This review suggests that early feeding may be associated with a trend toward better outcomes in terms of survival and disability. Further trials are required. These trials should report not only nutritional outcomes but also the effect on death and disability.