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Enteral nutrition in Traumatic Brain Injury

Isotonic solutions (such as Isocal® or Osmolyte®) should be used at full strength starting at 30 ml/ hr. Check gastric residuals q 4 hrs and hold feedings if residuals exceed ≈ 125 ml in an adult. Increase the rate by ≈ 15–25 ml/hr every 12–24 hrs as tolerated until the desired rate is achieved 1).

Dilution is not recommended (may slow gastric emptying), but if it is desired, dilute with normal saline to reduce free water intake.


Nasogastric tube feeding may interfere with absorption of phenytoin;

● reduced gastric emptying may be seen following head-injury 2) (NB: some may have temporarily elevated emptying) as well as in pentobarbital coma; patients may need IV hyperalimentation until the enteric route is usable.

The technique of hypocaloric feeding 3) (AKA “trophic feed,” “trickle feed,” among others) through an enteral feeding tube (e.g. Dobhoff tube) at a rate variously defined as at 10–20 ml/hr may be tolerated and may reduce mucosal atrophy while providing a portion of nutritional requirements. Others have described better tolerance of enteral feedings using jejunal administration 4)

In a review of the nutritional guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition, the articles cited demonstrate early transpyloric enteral feeds within 24 to 48 h significantly decrease morbidity and mortality 5) 6) 7) 8) 9) 10).

While these articles provide clear evidence that early nutrition is critical to survival, the most recent cited reference is 2012 and the articles lack the detail of which specific macro/micronutrients may benefit the traumatized brain. This is not a critique of the authors creating the guidelines but rather an observation of the need for serious large multi-institutional nutritional studies on TBI. Recently, there have been several studies demonstrating the highly beneficial effects of branched chain aminoacids (BCAAs) in the patient suffering mild to severe brain injury 11) 12) 13).

Clifton GL, Robertson CS, Contant CF, et al. Enteral Hyperalimentation in Head Injury. J Neurosurg. 1985; 62:186–193
Ott L, Young B, Phillips R, et al. Altered Gastric Emptying in the Head-Injured Patient: Relationship to Feeding Intolerance. J Neurosurg. 1991; 74: 738–742
Preiser JC, van Zanten AR, Berger MM, et al. Metabolic and nutritional support of critically ill patients: consensus and controversies. Crit Care. 2015; 19. DOI: 10.1186/s13054-015-0737-8
Grahm TW, Zadrozny DB, Harrington T. Benefits of Early Jejunal Hyperalimentation in the Head- Injured Patient. Neurosurgery. 1989; 25:729–735
Carney N, Totten AM, O’Reilly C, et al. Guidelines for the management of severe traumatic brain injury, 4th Ed. Neurosurgery. 2017;80(1):6-15.
Chourdakis M, Kraus MM, Tzellos T, et al. Effect of early compared with delayed enteral nutrition on endocrine function in patients with traumatic brain injury:an open- labeled randomized trial. J Parenter Enteral Nutr. 2012;36(1):108-116.
Dhandapani S, Dhandapani M, Agarawal M, et al. The prognositc significance of the timing of total enteral feeding in traumatic brain injury. Surg Neurol Int. 2012;3:31-36.
Acosta-Escribano J, Fernandez-Vivas M, Grau CT, et al. Gastric versus transpyloric feeding in severe traumatic brain injury: a prospective, randomized trial. Intensive Care Med. 2010;36(9):1532-1539.
Lepelletier D, Roquilly A, Demeure DL, et al. Retrospective analysis of the risk factors and pathogens associated with early-onset ventilator-associated pneumonia in surgical- ICU head-trauma patients. J Neurosurg Anesthesiol. 2010;22(1):32-37.
Hartl R, Gerber LM, Ni Q, Ghajar J. Effect of early nutrition on deaths due to severe traumatic brain injury. J Neurosurg. 2008;109(1):50-56
Jeter CB, Hergenroeder GW, Ward NH, et al. Human mild traumatic brain injury decreases circulating branched-chain amino acids and their metabolite levels. J Neurotrauma. 2013;15(8):671-679.
Elkind JA, Lim MM, Johnson BN, et al. Efficacy, dosage, and duration of action of branched chain amino acid therapy for traumatic brain injury. Front Neurol. 2015;30:66-73.
Sharma B, Lawrence DW, Hutchison MG. Branched chain amino acids (BCAAs) and traumatic brain injury: a systematic review. J Head Trauma Rehabil. 2017. doi: 10.1097/HTR.0000000000000280.
  • enteral_nutrition_in_traumatic_brain_injury.txt
  • Last modified: 2021/06/19 08:47
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