Nutritional Management of Critically Ill Trauma Patients in the Deployed Military Setting

Abstract

The role of nutritional support in critical illness is well established. This article reviews the nutritional management of military trauma patients in the deployed setting, which poses special challenges for the surgeon and intensivist. There is little direct evidence relating to the nutritional management of trauma patients in general, and military trauma patients in particular, but much of the evidence accrued in the civilian and non-trauma critical care setting can be extrapolated to military practice. There is strong consensus that feeding should be commenced as soon possible after injury. Enteral nutrition should be used in preference to parenteral nutrition whenever possible. If available, supplemental parenteral feeding can be considered if enteral delivery is insufficient. Gastrointestinal anastomoses and repairs, including those in the upper gastrointestinal tract, are not a contraindication to early enteral feeding. Intragastric delivery is more physiological and usually more convenient than postpyloric feeding, and thus the preferred route for the initiation of nutritional support. Feeding gastrostomies or jejunostomies should not be used for short-term nutritional support. Enteral feeding of patients with an open abdomen does not delay closure and may reduce the incidence of pneumonia, and enteral nutrition should be continued for scheduled relook surgery not involving hollow viscera or airway. Glutamine supplementation may improve outcome in trauma patients, but fish-oil containing feeds, while showing some promise, should be reserved for subgroups of patients with ARDS.group.bmj.com on June 22, 2015 -Published by

Improvised explosive device related pelvi-perineal trauma

“…46,47 Only a few articles have documented the importance of early nutrition on patients with specific pelviperineal trauma. 13,21,26,48 Birolini et al 13 documented the introduction of a standardized protocol for these patients after 1980, which in their institution showed a decrease in overall mortality from 70% to 31.5% and a reduction in sepsis rate from 50% to 18.4%. They claimed that full parenteral feeding introduced earlier and maintained for longer periods of time was mainly responsible for their figures.…”

“…It can also be continued in the days after initial injury when patients are returned to the operating theatre for non-airway and non-hollow viscus surgery. 48 We now recommend the use of early feeding in the MOST course, with the tube placed at time of initial surgery and feeding begun an hour or so later in the deployed ICU.…”

“…For those patients sustaining an ISS greater than 20, there were significantly fewer infections (p G 0.005) and in particular in the penetrating group (p G 0.05). 49 The nutritional management of critically ill trauma patients in the deployed military setting has been recently outlined 48 focusing on the practical aspects of delivering nutritional support. There was little evidence to commend the formation of a feeding jejunostomy for short-term nutritional support.…”