Early Enteral Combined with Parenteral Nutrition Treatment for Severe Traumatic Brain Injury: Effects on Immune Function, Nutritional Status and Outcomes

Abstract

Objective To compare the conjoint effect of enteral nutrition (EN) and parenteral nutrition (PN) with single EN or PN on immune function, nutritional status, complications and clinical outcomes of patients with severe traumatic brain injury (STBI). Methods A prospective randomized control trial was carried out from January 2009 to May 2012 in Neurological Intensive Care Unit (NICU). Patients of STBI who met the enrolment criteria (Glasgow Coma Scale score 6~8; Nutritional Risk Screening ≥3) were randomly divided into 3 groups and were admi- nistrated EN, PN or EN+PN treatments respectively. The indexes of nutritional status, immune function, complications and clinical outcomes were examined and compared statistically. Results There were 120 patients enrolled in the study, with 40 pationts in each group. In EN+PN group, T lymthocyte subsets CD3+%, CD4+%, ratio of CD3+/CD25+, ratio of CD4+/CD8+, the plasma levels of IgA, IgM, and IgG at 20 days after nutritional treatment were significantly increased compared to the baseline(t=4.32-30.00, P<0.01), and they were significantly higher than those of PN group (t=2.44-14.70; P<0.05,or P<0.01) with exception of CD4+/CD8+, higher than those of EN group (t=2.49-13.31, P<0.05, or P<0.01) with exceptions of CD3+/CD25+, CD4+/CD8+, IgG and IgM. For the nutritional status, the serum total protein, albumin, prealbumin and hemoglobin were significantly higher in the EN (t=5.87-11.91; P<0.01) and EN+PN groups (t=6.12-13.12; P<0.01) than those in PN group after nutrition treatment. The serum prealbumin was higher in EN+PN group than that in EN group (t=2.08; P<0.05). Compared to the PN group, the complication occurrence rates of EN+PN group were significantly lower in stress ulcer (22.5% vs. 47.5%; χ= 8.24, P<0.01), intracranial infection (12.5% vs 32.5%;χ= 6.88, P<0.01) and pyemia (25.0% vs. 47.5%; χ= 6.57, P<0.05). Compared to the EN group, the complication occurrence rates of EN+PN group were significantly lower in aspirated pneumonia (27.5% vs. 50.0%; χ= 6.39, P<0.05), hypoproteinemia (17.5% vs. 55.0%; χ= 18.26, P<0.01) and diarrhea (20.0% vs. 60.0%; χ= 20.00, P<0.01). The EN+PN group also had significant less length of stay in NICU (t=2.51, 4.82; P<0.05, P<0.01), number of patients receiving assisted mechanical ventilation (χ= 6.08, 12.88; P<0.05, P<0.01) and its durations (t=3.41, 9.08; P<0.05, P<0.01), and the death rate (χ=7.50, 16.37; P<0.05, P<0.01) than those of EN or PN group. Conclusion Early EN+PN treatment could promote the recovery of the immune function, enhance nutritional status, decrease complications and improve the clinical outcomes in patients with severe traumatic brain injury.

ESPEN guideline on clinical nutrition in the intensive care unit

“…Our meta-analysis including three studies [62,329,330] showed a decrease in length of stay (RR -0.47, CI -7.57, À1.71, p ¼ 0.002), a trend for decrease in mortality (RR 0.69, CI 0.39, 1.23, p ¼ 0.21), but no difference in incidence of pneumonia when early EN was administered. (see Meta-analysis IX in Supplemental Materials).…”

“…[62], in moderate traumatic brain injury, compared EN to PN after resuscitation and did not show any significant outcome difference. Fan et al [330] compared 3 groups: early EN, early PN and EN followed by supplemental PN. Mortality, complication were decreased significantly and nutritional status and clinical outcomes were improved in the early EN þ supplemental PN group [334].…”

Nutrition support in cardiac surgery patients: Be calm and feed on!

“…Guidelines already suggest that PN should be started in patients in whom EN cannot reach nutritional goals. Several randomized controlled studies have reported the effects of combined EN þ PN 23,31,32 and indicate a faster functional recovery in critically ill patients. Although EN is thought to be cheaper, safer, and more physiologic, and is recommended by international nutrition guidelines in critically ill patients without a contraindication to EN, 15,[33][34][35] recent data have demonstrated that combined PN þ EN is effective in increasing calorie and protein delivery during the first ICU week and thus may provide an advantage in cardiac surgery patients to rapidly achieve targeted nutritional goals in comparison with EN alone.…”

The implementation of a nutrition protocol in a surgical intensive care unit; a randomized controlled trial at a tertiary care hospital

“…Nonetheless, several trials have shown that the proper implementation of enteral-feeding protocols is able to reduce septic morbidity, ICU and hospital LOS, the need for mechanical ventilation, and mortality. [19][20][21][22] As those trials were observational in nature, the impact of an EN-feeding protocol requires further evaluation.…”