Nutrition in Clinical Practice

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surgical patients placed into pentobarbital-induced coma for intractable intracranial hypertension. Patients who had received at least 4 days of enteral nutrition ...

Nutrition in Clinical Practice

Tolerance and Efficacy of Enteral Nutrition for Neurosurgical Patients in Pentobarbital Coma Barbara Magnuson, Jimmi Hatton, Suzy Williams and Theresa Loan Nutr Clin Pract 1999 14: 131 DOI: 10.1177/088453369901400308 The online version of this article can be found at:

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CLINICAL RESEARCH Tolerance and Efficacy of Enteral Nutrition for Neurosurgical Patients in Pentobarbital Coma Barbara Magnuson, PharmD'%;Jimmi Hatton, PharmD, BCNSP'':; Suzy Williams, RD, CNSDf; and Theresa Loan, RN, (c)PhDf *College of Pharmacy, University of Kentucky Hospital, Lexington; ?Department of Nutrition Support Service, University of Kerituchy Hospital, Lexington

ABSTRACT: This retrospective study examined the tolerance of enteral nutrition in 32 of 67 consecutive, neurosurgical patients placed into pentobarbital-induced coma for intractable intracranial hypertension. Patients who had received at least 4 days of enteral nutrition were included. Patients with 500 ml watery stool for 2 days, abdominal distention, or duodenal-gastric reflux) was observed in 3 of 32 patients. The patients received daily, on average, 92% -t 24% calories of their measured energy expenditure. This study demonstrates that patients placed into barbiturate coma can be successfully fed by the enteral route.

Nutrition support is one of many clinical factors that influence neurologic recovery following traumatic brain injury (TBI).' Nutrition can be easily compromised in these patients. Attempts to establish enteral feeding access may exacerbate intracranial hypertension, which then contributes to delayed gastric emptying. Despite these considerable obstacles, nutrition support is essential for the patient with traumatic brain injury, and methods to improve administration need to be documented. Following the primary brain injury, activation of the sympathetic nervous system produces profound hypermetabolism and hypercatabolism.2 Energy expenditure is inversely correlated with the Glasgow Coma Scale (GCS) score.3 Hyperglycemia is

Correspondence: Barbara Magnuson, PharmD, University of Kentucky Hospital C-117,800 Rose Street, Lexington, KY 40536. 0881-5336/99/1403-0131$03.00/0 NUTRITIOS ISCLrrrcaL PPACTICE 14:131-131, June 1999 Copyright 0 1999 American Society for P a r e n t e d and Enteral Nutrition

associated with poor neurologic outcome. Increased calorie needs, along with access difficulties and electrolyte abnormalities, undermine efforts to provide adequate nutrition. The ability to provide nutrition support is often hindered when patients need neuromuscular blockers, pentobarbital-induced coma, or fluid restrictions. Brain injury produces delayed gastric emptying and intolerance to intragastric feeding.4 This is exacerbated when analgesics and sedative medications are components of the clinical management.5 Under these circumstances, the route of nutrition support requires strategies to reduce complications that are associated with secondary brain injury, such as intracranial hypertension or systemic hypotension. The enteral route often provides more protein and calories per volume compared with parenterally administered nutrients. This is especially true when total fluid intake is limited. This route also provides for improved maintenance of gastrointestinal mucosal integrity. Despite these advantages, delayed gastric motility, feeding-tube placement difficulties, and elevated intracranial pressure (ICP) often lead to hesitancy to pursue enteral access. Lack of gastric motility complicates transpyIoric placement of a small-bowel feeding tube by the blind bedside approach, and endoscopic placement may be needed.' Duodenal or jejunal access is required for reliable tolerance to enteral nutrition. Several studies in critically ill patients have reported positive benefits of providing early enteral nutrition. In the early postoperative period, most patients can tolerate the enteral route, and this is associated with a decrease in major infection^.^^^^^^'^ Enteral nutrition should be the preferred route of nutrition support in the neurosurgical patient because of the high energy demands and altered cellular immunity that contribute to the development of infections associated with brain injury."


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NCP, Vol. 14, No. 3, June 1999

Table 1. Nutritional data No. of patients (?r)


20(63%) 5(16%) 4 (13%) 1(3%) 1(3%) l(3CI) Total: 32

CHI SAH Open HI hleningitis BT AC

Avg. BEE (kcnl/d)"

Avg. NEE (kcnl/d)

Avg. kcal/d received

% rcceived (licnl/;\lEE)

(gfd) received

Avg. N, Balance (gfd)

1719 2 213 1754 i 172 1781 ? 210 1395 1392 1737 1712 i 208

2278 i 573 22904 t 177 2253 i 620 1410 1535 2140 2223 2 767

2117 k 541 1528 ? 436 1826 i 614 1883 1508 1758 1951 2 553

97.3 2 23 71 ? 27 82 i 11 134 66 82 90.7 2 24

102 2 28 53 t 25 76 i 27 77 91 80 90 i 30

-3.4 2 7.9 1.1 -C 4.0 -10.4 i 8.0 +2.5 -3.3 -8.2 -4.1 i 7.8

Avg. protein



_ _ _ _ ~

CHI, closed head injury; SAH, subarachnoid hemorrhages; €11, head injury; BT, brain tumor; AC, aneurysm clipping; BEE, basal energy expenditure; NEE, metabolic energy expenditure. *Results expressed as mean t standard deviation.

Many researchers have observed that this route of support is successful following traumatic brain in. jury; however, these studies excluded neurosurgical patients who were treated with pentobarbitalinduced coma. Pentobarbital-induced coma is a treatment for patients with refractory intracranial hypertension. Patients requiring this therapy are clinically distinct from other neurosurgical patients and often present with multiple factors that prevent adequate nutrient delivery. When required, pentobarbital is administered in doses that are sufficient to place a patient into a pharmacologic coma (GCS = 3). Barbiturates decrease the tone and amplitude of contractions in the gastrointestinal tract. This effect is peripherally and centrally mediated. At the pentobarbital level that is needed to induce coma, the drug action on the gastrointestinal tract is caused primaril by its central nervous system depressant activity.% There is a limited amount of literature that exists to help the practitioner guide nutrition support decisions for these complicated patients. The observed positive relationship between outcome and nutrition following TBI necessitated evaluation of enteral nutrition tolerance in neurosurgical patients placed into pentobarbital-induced coma. hIETHOD

Neurosurgical patients admitted from October 1992 through February 1996 were retrospectively evaluated as part of a quality assurance review for nutrition support. We included Neurosurgical Service patients who had been placed into pentobarbital-induced coma and who had received a t least four consecutive days of enteral nutrition. We arbitrarily chose four days of enteral nutrition while in barbiturate coma to assess feeding tolerance. All patients were fed through a sniall-bore feeding tube placed blindly or endoscopically. Feeding-tube placement was confirmed radiographically before initiating

enteral nutrition in all but two patients. Intolerance to enteral nutrition was defined as: watery diarrhea of 500 ml or greater on two consecutive days,13 duodenal-gastric reflux of tube feeding as determined by visual inspection of the gastric residual for tube feeding, or a severely distended abdomen that required altering the hourly volume of enteral nutrition. The basal energy expenditure (BEE) was calculated using the Harris-Benedict equation. Measured energy expenditure was determined by indirect calorimetry (Deltatrac Metabolic hlonitor by Sensormedics, Yorba Linda, CA) in all patients. Indirect calorimetry was performed per protocol order at the initiation of enteral nutrition and then weekly while in the intensive care unit (ICU). Twenty-four-hour urine urea nitrogen samples were collected to determine nitrogen balance. Four grams of nitrogen were added to nitrogen output to compensate for nonmeasured nitrogen losses. The number of days in coma and number of enteral nutrition days in coma were identified. The enteral product and daily volume were used to calculate the total daily calories, nonprotein calories, and protein intake. The caloric balance was recorded as a percentage of the total calorie intake compared with the measured energy expenditure (MEE) during pentobarbital coma. RESULTS

Demographics. Sixty-seven neurosurgical patients were placed into pentobarbital-induced coma. Of those, 32 (25 men and 7 women) met entry criteria (Table 1).We excluded 35 patients for reasons that were unrelated to feeding intolerance. For example, we could not determine enteral tolerance in a patient who was in barbiturate coma for