Nutritional support: a prophylaxis against stress bleeding after spinal cord injury

Abstract

SummaryThe incidence of upper gastrointestinal (UG /) bleeding and the effect of nutritional support was studied retrospectively in 166 spinal cord injured patients. Sixty six patients included in group 1 were started on oral diet when 'clinically ready' which resulted in a haphazard manner for provision of nutrition. One hundred patients in group 2 were treated according to an organised nutrition protocol. The protocol initiates total parental nutrition (TPN) If the patient is not tolerating an oral diet by day 5. All group 2 patients met their total energy requirements (TER) within 48 hours after initiating caloric supplementation.The overall incidence of acute acid peptic ulceration leading to significant bleeding or perforation was 4%. Five of the 66 group 1 patients (7.5'jo) and 2 of the 100 group 2 patients (2%) developed acute ulcerations. While the exact mechanism remains unclear, this significant (p < 0·05) reduction indicates that a nutritional regimen that meets a patients TER decreases the likelihood of acid peptic complica tions after spinal cord injury.

Acute Management of Nutritional Demands after Spinal Cord Injury

“…An organized nutritional protocol (supplemental parenteral nutrition to meet defined energy requirements is initiated if not tolerating an enteral diet) significantly decreases the likelihood of upper GI bleeding, and allows patients to reach total energy requirements nearly threefold faster (Kuric et al, 1989). Although enteral feeding has historically been delayed in SCI patients secondary to concerns about ileus and other complications, studies have found that feeding these patients within the first 72 h is safe (Dvorak et al, 2004;Rowan et al, 2004) Discussion Unlike other trauma patients, such as those with traumatic brain injury, burns, or multi-trauma, patients with SCI do not demonstrate hypermetabolism following injury (Kearns et al, 1992;Kolpek et al, 1989;Rodriguez et al, 1991Rodriguez et al, , 1997.…”

Safety of Enteral Feeding in Patients With Open Abdomen, Upper Gastrointestinal Bleed, and Perforation Peritonitis

“…A prospective study, published in 1989, examined 166 patients with spinal cord injury and suggests that there may be a time advantage to feeding patients. 45 The authors observed a statistically significant reduction in the incidence of GIB (7.6% to 2%) when the time to initiation of EN was reduced from 15.5 to 4.6 days. In a larger retrospective historical control study, Raff et al 46 demonstrated that EEN (within 12 hours posttrauma) was associated with a lower GIB rate than cimetidine or antacid therapy.…”

“…A prospective study, published in 1989, examined 166 patients with spinal cord injury and suggests that there may be a time advantage to feeding patients 45 . The authors observed a statistically significant reduction in the incidence of GIB (7.6% to 2%) when the time to initiation of EN was reduced from 15.5 to 4.6 days.…”

Gastrointestinal Prophylaxis in Neurocritical Care

“…A positive nitrogen balance develops after feeding, Neurocrit Care (2012) 16:184-193 189 resulting in a dilutional alkalinization from a gastric feeding tube and the reparative effects on the gastric mucosa that are possible explanations for this. Kuric et al [38] retrospectively demonstrated significantly lower incidence of GUD in patients with SCI when enteral nutrition was used. The combination of enteral nutrition and stress ulcer prophylaxis with ranitidine conferred significantly lower GI bleeding rates in blinded studies [77].…”

“…Incidence of gastric ulcer disease (GUD) is commonly accentuated after SCI, ranging between 2 and 20% [35][36][37][38][39]. Further studies have postulated a multi-factorial causation [2, 38, and 40].…”