Nutritional Support: Route (Total Parenteral versus Total Enteral)

Published 2003
Citation: J Trauma. 57(3):660-679, September 2004.

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I. Statement of the Problem

The metabolic response to injury mobilizes amino acids from lean tissues to support wound healing, immunologic response and accelerated protein synthesis. The goal of aggressive early nutrition is to maintain host defenses by supporting this hypermetabolism and preserve lean body mass. The route of nutrient administration affects these responses, and the benefits of early enteral feeding have been clearly shown. Laboratory and clinical studies reveal beneficial affects of early nutrition on the gut mucosa, immunologic integrity, survival of septic peritonitis, pneumonia, and abscess formation.

Therefore the question arises as to the route to deliver nutrition to the traumatized hypermetabolic patient with multisystem injuries including severe head injuries, burns, and blunt and penetrating mechanisms. There are certainly risks and benefits to enteral and parenteral nutrition in this complicated patient population. The purpose of this review is to determine the benefits and the risks of the route of nutrition in the severely injured patient through peer reviewed publications over the past 25 years and to develop recommendations and guidelines from the conclusions of these studies based on the scientific methodology of these studies.

II. Process

A. Identification of References

References were identified from a computerized search of the National Library of Medicine for English language citations between 1976 and 2000. Keywords included nutrition, enteral, parenteral, trauma, injury, and burn. The bibliographies of the selected references were reviewed for relevant articles not found in the computerized search. Literature reviews, case reports, and editorials were excluded. Twenty-eight articles were identified.

B. Quality of the References

The quality assessment instrument applied to the references was developed by the Brain Trauma Foundation and subsequently adopted by the EAST Practice Management Guidelines Committee. Articles were classified as Class I, II, or III according to the following definitions:

Class I: A prospective, randomized clinical trial. Fourteen articles were chosen and analyzed.

Class II: A prospective, non-comparative clinical study or a retrospective analysis based on reliable data. Ten articles were chosen and analyzed.

Class III: A retrospective case series or database review. Four articles were chosen and analyzed.

III. Recommendations

A. Level I

Patients with blunt and penetrating abdominal injuries should, when feasible, be fed enterally because of the lower incidence of septic complications compared with parenterally fed patients.

B. Level II

Patients with severe head injuries should preferentially receive early enteral feeding, since outcomes are similar compared with parenterally-fed patients. If early enteral feeding is not feasible or not tolerated, parenteral feedings should be instituted.

C. Level III

  1. In severely injured patients, TPN should be started by day 7 if enteral feeding is not successful.
  2. Patients who fail to tolerate at least 50% of their goal rate of enteral feedings by post-injury day 7 should have TPN instituted but should be weaned when > 50% of enteral feedings are tolerated.

IV. Scientific Foundation

Moore and Jones[1] reported the benefits of enteral feedings using immediate jejunal feedings in 1986. The patients in this study had laparotomy for severe abdominal injuries (abdominal trauma index [ATI] >15). Nutritional parameters and overall complications were not different between the enterally and parenterally fed groups; the septic morbidity was higher in the parenterally fed group (p <0.025). Peterson et al.[2] further evaluated this effect and reported that acute phase proteins increased from baseline to a higher extent in the TPN group compared with TEN in patients suffering abdominal trauma with an ATI >15, <40. The TPN group reached a nadir in constitutive proteins at day 10, while the TEN group had a rise in serum albumin and retinol-binding protein (p <0.05). In 1989, Moore et al.[3] reported further evidence of the reduced septic complications in patients (ATI >15, <40) fed enterally versus parenterally. A meta-analysis of eight prospective, randomized trials attests to the feasibility of early postoperative enteral feedings in high-risk surgical patients. These patients had reduced septic morbidity rates compared with patients fed parenterally.[4] In 1992 and 1994, Kudsk et al.[5] [6] showed further evidence of the effectiveness of enteral nutrition over parenteral nutrition. In the earlier study, the rate of septic complications including pneumonia, intra-abdominal abscess, and line sepsis were significantly reduced in the enterally fed group of patients with an ATI >15. Furthermore, the sicker patient (ATI >24, ISS >20, transfusions >20 units, and re-operation) had significantly fewer infections. The latter study confirmed the previous report of Peterson et al.[2] concluding that enteral feeding produces greater increases in constitutive proteins and greater decreases in acute-phase proteins after severe trauma. This is primarily caused by reduced septic morbidity with enteral feeding. Other factors involved in the reduced septic complications include bacterial translocation, endotoxin, interleukins 1, 2, 6, 11, and 12, and macrophage stimulation. These effects are beyond the scope of this review.

One potential disadvantage regarding the enteral approach to nutrition of the trauma patient is the concern that adequate amounts of protein and calories cannot be delivered via this route, due to frequent interruptions in feeding because of multiple operative procedures. Moncure and coworkers have recently shown that, in selected patients, enteral feedings can be safely administered up to the time of transport to the operating room. This approach facilitated delivery of greater amounts of protein and calories without an increase in peri-operative aspiration events.[7]

In the head-injured patient, the optimal route of administration remains controversial as both routes are effective and each has advantages and disadvantages. One of the earliest studies to show a benefit to the early use of parenteral feedings was by Rapp et al.[8] in 1983. Patients with severe head injury were randomly assigned to receive enteral or parenteral nutrition. Patients receiving TPN within 72 hours of admission had a lower mortality rate (p<0.0001). Haussman and colleagues[9] found that combined parenteral and enteral feeding was comparable to parenteral feeding alone with regard to mortality, nitrogen-balance, creatinine, and 3­methylhistidine excretions, but noted that brain-injured patients with impaired gastric function (as evidenced by high gastric residuals), were better treated with parenteral nutrition. Hadley and others[10] further demonstrated the equal effectiveness of each route. Although the parenteral nutrition group had higher mean daily nitrogen intakes (p<0.01) and mean daily nitrogen losses (p<0.001), there were no significant differences in serum albumin levels, weight loss, incidence of infection, nitrogen balance, and final outcome. A series of studies performed by Young and others[11] [12], and Ott and colleagues[13]further defined nutritional support in the head-injured patient. In the laboratory, intravenous hyperosmolar solutions were found to potentiate cerebral edema following head injury. In 1987, Young et al.[11] reported no significant difference in peak ICP, failed therapy of ICP, serum osmolality, morbidity or mortality, and patient outcome in patients receiving parenteral compared with enteral nutrition. Young et al.[12] then reported on 51 brain-injured patients in a prospective, randomized trial of parenteral versus enteral nutrition. Not only did the parenteral support patients have better outcomes at 3, 6, and 12 months, but the enteral group had a higher septic complication rate (p<0.008), believed to be due to lower total protein intake, cumulative caloric balance, and negative nitrogen balance. The enterally fed group did not tolerate feedings until a mean of 9 days, and received fewer calories and less protein. Ott et al.[13] studied enteral feeding intolerance in head-injured patients. They noted that gastric emptying was biphasic and that a majority of brain-injured patients displayed delayed gastric emptying during the post-injury week 1. This delayed and biphasic response persisted through the second week in >50% of the patients. By week 3, most patients exhibited rapid gastric emptying, and all patients tolerated full volume enteral feedings by day 16. Borzotta and colleagues[14] confirmed the efficacy of enteral and parenteral support using early jejunal feedings in the enteral group and delayed gastric feeding (day 5-9) in the parenteral group. No difference was found regarding measured energy expenditure, protein intake, albumin, transferrin, nitrogen balance, infectious rates, or hospital costs. Thus it appears that, in the head-injured patient, establishment of early and consistent enteral feeding may obviate the need for parenteral nutrition in this patient population. These related issues of timing (early versus late) and site (gastric versus jejunal) of enteral feeding are discussed in greater detail later in this report. Much of this information has been summarized recently in an excellent review published by the Cochrane Library .[15]

The relative superiority of enteral over parenteral nutrition in the trauma patient should not be used as an excuse for delaying appropriate nutritional support. Total starvation for less than 2 to 3 days in healthy adults causes only glycogen and water losses and minor functional consequences. Functional deficits are evident in healthy normal weight adults who voluntarily restrict food intake after about 15 days of semi-starvation. Many trauma patients are hypermetabolic, and depletion of nutrient stores proceeds more rapidly in the case of total starvation than it does in healthy adults. The functional consequences of total or partial starvation thus evolve more rapidly in the stressed and catabolic patient than in healthy individuals. For these reasons, most investigators recommendachievement of the severely injured patient’s nutritional support goals by post-injury day 7, whether by enteral or parenteral means, or some combination of the two.[16]

V. Summary

Although the evidence is not abundant, there is scientific support that patients with blunt and penetrating abdominal injuries sustain fewer septic complications when fed enterally as opposed to parenterally. The surgeon must be aware of the potential benefits of enteral feedings in these severely injured patients. The trauma surgeon caring for patients with head injury must weigh the benefits and the risks of the route of nutrient administration, as patients with severe head injuries have similar outcomes whether fed enterally or parenterally. As determined in studies of malnutrition and starvation, the hypermetabolic state of the severely injured patient requires that calorie and protein goals should be achieved by day 7. Patients who fail to tolerate at least 50% of their goal rate of enteral feedings by this time should have TPN instituted.

VI. Future Investigation

Many of the issues related to the route of nutrition in the trauma patient are far from settled. Although the benefits of enteral nutrition in the severely injured patient with abdominal trauma are well documented, the mechanisms (immunologic and physiologic) remain unclear. The route of administration of enteral feedings, the nutrient composition, and the long-term outcome of trauma patients are still areas for future evaluation by clinicians and scientists. The effectiveness of nutritional support in the severely head-injured patient remains a difficult area to evaluate, as the injury itself remains the most significant factor in the outcome of the patient. Prospective studies of nutritional support evaluating long-term outcomes are still required. Previous work has demonstrated the safety and efficacy of enteral and parenteral nutrition in head-injured patients, but their exact roles or the preference of either route has not been demonstrated. Further study is required to determine a cost-effective approach to nutritional support that may improve outcome in severely head-injured patients.

References

  1. Moore EE, Jones TN. Benefits of immediate jejunostomy feeding after major abdominal trauma: a prospective randomized study. J Trauma. 1986;26:874-881.
  2. Peterson VM, Moore EE, Jones TN, et al. Total enteral nutrition versus total parenteral nutrition after major torso injury: attenuation of hepatic protein synthesis. Surgery. 1988;104:199-207.
  3.  Moore FA, Moore EE, Jones TN, McCroskey BL, Peterson VM. TEN versus TPN following major abdominal trauma - reduced septic morbidity. J Trauma. 1989;29:916-922.
  4. Moore FA, Feliciano DV, Andrassy RJ, et al. Early enteral feeding, compared with parenteral, reduces postoperative septic complications. The results of a meta-analysis. Ann Surg.1992;216:172-183.
  5. Kudsk KA, Croce MA, Fabian TC, et al. Enteral versus parenteral feeding. Effects on septic morbidity after blunt and penetrating abdominal trauma. Ann Surg. 1992;215:503-513.
  6. Kudsk KA, Minard G, Wojtysiak SL, Croce M, Fabian T, Brown RO. Visceral protein response to enteral versus parenteral nutrition and sepsis in patients with trauma. Surgery. 1994;116:516-523.
  7. Moncure M, Samaha E, Moncure K, et al. Jejunostomy tube feedings should not be stopped in the perioperative patient. J Parenter Enteral Nutr. 1999;;23:356-359.
  8. Rapp RP, Young B, Twyman D, et al. The favorable effect of early parenteral feeding on survival in head injured patients. J Neurosurg. 1983;58:906-912.
  9. Hausmann D, Mosebach KO, Caspari R, Rommelsheim K. Combined enteral-parenteral nutrition versus total parenteral nutrition in brain-injured patients. A comparative study. Intensive Care Med. 1985;11:80-84.
  10. Hadley MN, Grahm TW, Harrington T, Schiller WR, McDermott MK, Posillico DB. Nutritional support and neurotrauma: a critical review of early nutrition in forty-five acute head injury patients. Neurosurgery. 1986;19:367-373.
  11. Young B, Ott L, Haack D, et al. Effect of total parenteral nutrition upon intracranial pressure in severe head injury. J Neurosurg. 1987;67:76-80.
  12. Young B, Ott L Twyman D, et al. The effect of nutritional support on outcome from severe head injury. J Neurosurg. 1987;67:668-676.
  13. 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.
  14. Borzotta AP, Pennings J, Papasadero B, et al. Enteral versus parenteral nutrition after severe closed head injury. J Trauma. 1994;37:459-468.
  15. Yanagawa T, Bunn F, Roberts I, Wentz R, Pierro A. Nutritional support for head-injured patients. [Review] Cochrane Database of Systematic Reviews [computer file] 2000;(2):CD001530.
  16. ASPEN Board of Directors. Guidelines for the use of parenteral and enteral nutrition in adult and pediatric patients. J Parenter Enteral Nutr. 1993;17:20SA.
  17. Kalfarentzos F, Kehagias J, Mead N, Kokkinis K, Gogos CA. Enteral nutrition is superior to parenteral nutrition in severe acute pancreatitis: results of a randomized prospective trial. Br J Surg. 1997;84:1665-1669.
  18. Heyland D, Cook DJ, Winder B, Brylowski L, Van demark H, Guyatt G. Enteral nutrition in the critically ill patient: a prospective survey. Crit Care Med. 1995;23:1055-1060.
  19. Raff T, Hartmann B, Germann G. Early intragastric feeding of seriously burned and long-term ventilated patients: a review of 55 patients. Burns. 1997;23:19-25.
  20. Spapen H, Duinslaeger L, Diltoer M, Gillet R, Bossuyt A, Huyghens LP. Gastric emptying in critically ill patients is accelerated by adding cisapride to a standard enteral feeding protocol: results of a prospective, randomized, controlled trial. Crit Care Med. 1995;23:481-485.
  21. Hadfield RJ, Sinclair DG, Houldsworth PE, Evans TW. Effects of enteral and parenteral nutrition on gut mucosal permeability. Am J Resp Crit Care Med. 1995;152:1545-1548.
  22. Adams S, Dellinger EP, Wertz MJ, Oreskovich MR, Simonowitz D, Johansen K. Enteral versus parenteral nutritional support following laparotomy for trauma: a randomized prospective trial. J Trauma. 1986;26:882-891.
  23. Bethel R, Jansen RD, Heymsfield SB, Ansley JD, Hersh T, Rudman D. Nasogastric hyperalimentation through a polyethylene catheter: an alternative to central venous hyperalimentation. Am J Clin Nutr. 1979;32:1112-1120.
  24. Page CP, Carlton PK, Aandrassy RJ, Feldtman, RW, Shield CF. Safe, cost-effective postoperative nutrition. Defined formula diet via needle-catheter jejunostomy. Am J Surg.1979;138:939-945.
  25. Eyer SD, Micon LT, Konstantinides FN, et al. Early enteral feeding does not attenuate metabolic response after blunt trauma. J Trauma. 1993;34:639-644.
  26. Jones TN, Moore FA, Moore EE, McCroskey BL. Gastrointestinal symptoms attributed to jejunostomy feeding after major abdominal trauma: a critical analysis. Crit Care Med.1989;17:1146-1150.
  27. Norton JA, Ott LG, McClain C, et al. Intolerance to enteral feeding in the brain-injured patient. J Neurosurg. 1988;68:62-66.
  28. Grahm TW, Zadrozny DB, Harrington T. Benefits of early jejunal hyperalimentation in the head-injured patient. Neurosurgery. 1989;25:729-735.

Table

Route of Nutritional Support Evidentiary Table

First AuthorYearClassConclusions

Rapp [8]

1983

I

38 patients with blunt/penetrating head injury randomized within 48 hours to TPN (n=20, age 29.2 years, GCS score 7.7) or intragastric feeding (n=18, age 34.9 years, GCS score 7.2) with defined formula diet. Enteral caloric intake <400 cal/day for first day, <600 cal/day for first 10 days, and <900 cal/day for 14 days due to delayed gastric emptying. Eight of 18 patients fed enterally died within 18 days compared with 0 TPN patients. Prolonged gastroparesis occurred with intragastric feeding post severe head injury.

Hausmann [9]

1985

I

20 patients randomized to enteral-parenteral nutrition (n=10) and TPN (n=10) after suffering severe brain injury (GCS score 5-7). There were no differences in protein intake, nitrogen balance, or mortality between the groups. Both regimens were nutritionally effective, but impaired gastric emptying hampered enteral feedings.

Adams [22]

1986

I

46 multiple trauma patients post-laparotomy were randomized to receive enteral nutrition via needle catheter jejunostomy or TPN. There were no differences in nitrogen balance or postoperative complications. Early enteral nutrition is safe.

Hadley [10]

1986

I

45 head-injured patients with GCS score <10 randomized to intragastric (n=21, GCS score 5.9) feeding with standard commercial diet or TPN (n=24, GCS score 5.8). Enteral patients achieved positive caloric balance (140% of BMR) in 5% on day 2, 45% on day 3, 70% on day 4, and between 70% and 85% on day 11. TPN achieved >80% by day 5 and 100% by day 9. Complication rate and infectious rate similar. Use TPN only when gastrointestinal tract fails to work. Editorial: gastroparesis begins to resolve on day 3 to 4. Do not wait for nasogastric drainage to drop or bowel sounds to return.

Young [11]

1987

I

96 severely brain-injured patients were randomized to receive early TPN or enteral feedings when tolerated. There were no differences in the groups including: admitting GCS score, number of craniotomies, MOI, ICP>20, failure of conventional therapy, barbiturate failure, or serum osmolality. TPN can be used safely, but there is no outcome advantage to enteral feeding.

Young [12]

 

1987

 

I

 

51 evaluable of 58 consented patients with GCS score 4-10 after blunt or penetrating head wounds randomized to TPN (n=23, age 30.3 years, GCS score 7.0) or intragastric feedings (n=38, age=34.0 years, GCS score 6.5) after bowel sounds return and nasogastric drainage dropped below 100 mL. Enteral patients received <500 cal/day for first 2 days (versus 1221 kcal TPN group), <1500 cal/day for days 6-8 (versus 2350 kcal in TPN group) due to gastroparesis. Infectious complications were the same and neurologic outcome similar at 1 year. Prolonged gastroparesis occurs after severe head injury.

Grahm [28]

1989

I

32 patients with blunt/penetrating wounds and GCS score =10 randomized (by admission day) to nasojejunal feeding via fluoroscopy by 36 hours (age 25.5 years, GCS score 5.1) and started at goal rate or intragastric feedings after day 3 if gastrointestinal function returned (age 27.8 years, GCS score 7.1). Caloric intake matched measured need by day 3 with jejunal tube and approached 75% of need on day 5-7. With intragastric feedings, there were significantly fewer bacterial infections (bronchitis: 3-4 plus WBC in sputum with positive cultures) than with jejunal feedings. Goal rates achieved faster with small bowel access. Gastric residuals limit intra-gastric feeding rate. No change in metabolic rate by indirect calorimetry.

Jones [26]

1989

I

123 patients requiring emergent laparotomy (ATI >15) were prospectively randomized to non-enteral feeding (n=52) or enteral feeding (n=71) by means of a needle jejunostomy catheter. 50% of control group had gastrointestinal symptoms (12% moderate discomfort). 83% of enteral-fed group had symptoms; 16% moderate symptoms, 13% required TPN. 87% tolerated enteral feedings, 35 cal/kg/day and 14.5 g nitrogen/day by post-operative day 5.

Moore FA [3]

1989

I

59 patients with major abdominal trauma were randomized to receive TEN or TPN after laparotomy. Patients who received enteral nutrition had fewer septic complications. In addition, nutritional protein markers were restored faster in the TEN group.

Kudsk [5]

1992

I

98 trauma patients were randomized to receive TPN or enteral nutrition within 24 hours of penetrating or blunt abdominal trauma. There was a lower incidence of septic complications in the patients who received enteral nutrition.

Eyer [25]

 

1993

 

I

 

38 evaluable patients randomized to early (starting 31 hours after ICU admission) compared with late (82 hours) feeding via nasoduodenal tubes. ISS was similar; however, 58% of early group had severe acute lung injury versus only 21% in late group. Target rates in most patients were reached within 12 hours of start, with advancement to 25 mL every 4 hours. Excellent small bowel tolerance with no intra-abdominal injury within 1.5 days of injury but no differences in ICU or ventilator days, organ system failure, or infections (question of higher infection rate with early group but included eye, sinus, and urinary infections probably unrelated to enteral feeding).

Kudsk [6]

1994

I

68 patients randomized to enteral (n=34, ATI 28.0, ISS 27.0) or parenteral (n=34, ATI 27.8, ISS 26.8) nutrition. Significantly higher levels of constitutive proteins and lower levels of acute-phase protein were noted in the enteral group. An important factor related to route of nutrition was the significant reduction in septic morbidity (any infection, pneumonia, line sepsis) associated with enteral nutrition.

Borzotta [14]

1994

I

48 evaluable head-injured patients (GCS score <8) randomized to TPN (n=21, age 28.9 years, ISS 33.4, GCS score 5.4) or enteral feeding via surgically placed jejunostomies (n=27, age 26.2 years, ISS 32.5, GCS score 5.2) and started within 72 hours of injury. All TPN patients had initial attempts with intragastric feeding (and presumably failed). TPN transition to intragastric feedings started on day 5. Diarrhea was more common in TPN patients, and they had a high rate of nasogastric tube dislodgment. Enterally delivered calories equaled 90.5% of measured resting energy expenditure by indirect calorimetry by day 3. With direct small bowel access, nearly achieved calculated goal by day 3 (and subsequently over) with little intolerance.

Spapen [20]

1995

I

21 mechanically ventilated patients were randomized to receive cisapride 10 mg four times daily or no cisapride with tube feedings. Gastric residue was measured using bedside scintigraphy. Patients in the cisapride group had accelerated gastric emptying. This was statistically significant.

Page [24]

1979

II

199 patients post-elective major abdominal and post-emergent abdominal surgery were fed by needle-catheter jejunostomy and monitored for complications. Patients’ nutritional status was adequately maintained. The complication rate was 2.5%. Jejunostomy feeding is safe in the postoperative period.

Moore EE [1]

1986

II

75 patients post-celiotomy for abdominal trauma were randomized to receive enteral nutrition via needle jejunostomy or intravenous fluids. Enteral nutrition was started within the first 24 postoperative hours. Nitrogen balance was improved in the patients receiving enteral nutrition, and there were fewer septic complications.

Norton [27]

1988

II

23 patients with blunt/penetrating head injury and GCS score 4-10 (average 6.6) were followed for enteral tolerance. Feedings were started when drainage was <200 mL/day, and bowel sounds were present. Seven patients tolerated feedings within 7 days, four between 7­10 days, and 12 never tolerated feedings with a trend toward greater intolerance with lower GSC. Tolerance did not correlate with bowel sounds. Gastroparesis occurs in most patients with severe head injury.

Peterson [2]

1988

II

Hepatic synthesis of acute phase reactant proteins was evaluated in 59 patients with an ATI between 15 and 40. 36 patients completed the trial, of which 18 patients received TPNand 18 received enteral nutrition. The group receiving enteral nutrition had earlier attenuation of the acute-phase reactant protein production.

Ott [13]

1991

II

12 head-injured patients (GCS score 4-10) were evaluated during their hospital stay for liquid gastric emptying. 50% had delayed gastric emptying for up to 7 days, 40% normal within 14 days, and 80% had normal or biphasic emptying by 16 days. Patients with normal or rapid emptying (30%) tolerated full feedings in 8.5 days, which was significantly earlier than the patients with delayed gastric emptying (50%, 13.7 days).

Moore FA [4]

1992

II

A meta-analysis of eight prospective randomized trials to compare the efficacy of early enteral nutrition with TPN in high-risk surgical patients. Patients who received enteral nutrition had fewer septic complications.

Hadfield [21]

1995

II

24 patients were randomly allocated to receive TPN or enteral nutrition. Gastrointestinal absorption was evaluated by measuring D-xylose and 3-O methyl glucose, and gastrointestinal tract permeability was determined by measuring lactulose and L-rhamnose. All critically ill patients had gastrointestinal tract dysfunction; however, mucosal integrity was restored by giving enteral nutrition.

Heyland [18]

 

1995

 

II

 

A prospective cohort study that evaluated the factors associated with initiation and tolerance of enteral nutrition in 99 critically ill patients. The authors reported that enteral nutrition was not initiated in all eligible patients, and 50% of the patients receiving enteral nutrition tolerated the regimen

Kalfarentzos [17]

1997

II

A prospective randomized trial of 38 patients with acute severe pancreatitis; 20 received TPN and 18 received elemental enteral nutrition. Enteral feedings were tolerated well, and patients had fewer complications.

Moncure [7]

1999

II

Prospective, non-randomized study of 82 trauma patients with jejunostomy tubes who required non-abdominal surgery. 46 patients had tube feedings continued up until the time of transport to the operating room (fed group), and 36 patients had feedings stopped at midnight before the operation. Aspiration of tube feedings did not occur in either group, and the fed group received more protein and calories on the operative day and on post­operative day 1.

Bethel [23]

1979

III

Enteral nutrition was given to 12 patients referred for TPN. Patients showed weight gain and improvement in serum albumin levels. Nasogastric feedings are a safe alternative to TPN.

ASPEN Board of Directors [16]

1993

III

Many trauma patients are hypermetabolic. The functional consequences of total or partial starvation evolve more rapidly in the stressed and catabolic patient than in healthy individuals. For injured patients, severely limited nutrient intake should not exceed 7 days.

Raff [19]

1997

III

A retrospective review of 55 burn patients receiving early intragastric feeding. Patients who tolerated the early feeding had significantly lower mortality rates.

Yanagawa [15]

2000

III

Review of 12 randomized, controlled trials, focusing specifically on the timing and route of nutritional support following acute traumatic brain injury. 257 patients of all ages with traumatic brain injury of any severity either isolated or part of multisystem injury were included. Authors conclude that early feeding may be associated with fewer infections and a trend toward improved survival and long-term disability. There was a trend toward better outcomes with parenteral nutrition (compared with enteral), but this observation may be related, in part, to the delay in starting enteral feedings due to associated gastric ileus. Overall, the quality of the trials was poor, and the authors recommended larger trials with more relevant clinical endpoints.

TPN, total parenteral nutrition; GCS, Glasgow Coma Scale; BMR, basal metabolic rate; MOI, Mechanism of Injury; ICP, intracranial pressure; ATI, abdominal trauma index; TEN, total enteral nutrition, ICU, intensive care unit

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