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Case Study: Traumatic Brain Injury

Brain Injury Patient at CCH
by

Jessica de Wit

on 10 April 2011

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Transcript of Case Study: Traumatic Brain Injury

Traumatic Brain Injury Injury secondary to rapid movement
of the brain within the skull caused
by an external mechanical force. TBI o Motor vehicle accidents
o Falls
o Acts of violence
o Industrial accidents
o Contact sports Brief loss of consciousness
No evidence of damage on CT or MRI Concussion "Bruise" : Damage to capillaries and swelling
Detected by CT and MRI.
Damage resolved. Contusion Shearing of axons from rotational accelerated movement in the skull; Corpus callosum generally affected;
Usually permanent damage. Diffuse axonal injury Types of TBI - The Brain Injury Association of Canada
- Krause’s Food, Nutrition & Diet Therapy, 12th Edition 15 point scale used to quantify level of consciousness and often severity of TBI
(Speech, Motor function, Eye opening) Glasgow Coma Scale o GCS < 8 = Severe Brain Injury
o GCS 9- 13 = Moderate Brain Injury
o GCS 14-15 = Minor Brain Injury
• Primary injuries

• Secondary injury: inflammatory and metabolic response
to primary injury Physical and cognitive consequences
o Brain cell swelling and apoptosis (Hemorrhage)
o Increased intracranial pressure (ICP)
o Ischemia; Hypoxia Fractures, bruises, lacerations •
o Paralysis, loss of function
o Delayed gastric emptying, malabsorption
o Seizures and headaches •
- social skills
- dependence
- perception
- insight
- communication
- memory
- behaviour,
- etc...

Depression Brain= Regulator of Metabolism !! Hypermetabolism = severity of TBI •- oxygen consumption
- caloric requirements
- cardiac workload Catecholamines
(epinephrine and norepinephrine) • Hyperglycemia
↓Mg ++


Free radical production
•-wound healing

•-serum proteins

- serum Zn ↑ IL-1 & IL-6

Cell-Mediated Immunity Increased Catabolism cortisol
epinephrine
norepinephrine
glucagon


o Exacerbated by corticosteroid therapy
• ↑
o Gluconeogenesis



- Mobilization of amino acids from skeletal muscles
- →Nitrogen losses
→ - Weight loss (2 months post-injury)
→ - Muscle wasting exacerbated by immobility Catecholamines & Glucocorticoids Psycho-social ++ Disruption of cellular metabolism
=
++ Cell death
• Treatment of ICP
• Increased Salt Wasting
• Increased ADH Fluid and electrolyte imbalance: Case Study: Jessica de Wit, Nutrition Intern Presentation by: Cornwall Community Hospital
April 11, 2011 30 year old male injured in a motor vehicle accident (ATV vs. Van).
Subject was found 10 ft from the scene, wearing helmet.
Subject suffered a traumatic brain injury.
Glasgow Coma Scale of 6 at the scene (indicating severe brain injury). • Diffuse axonal injury of the frontal lobes
• Right basal gangliar intraventricular hemorrhage
• Intraparenchymial hemorrhage
• Corpus callosum hemorrhage with encephalomalacia
• No midline shift
• Fractures x 2 Injuries Admitted to ICU at the Ottawa Hospital, where nutritional assessment and intervention were completed/initiated on the same day by RD: January 17 2011 during critical phase of injury Nutrition Care
• Protect airway
• Promote adequate oxygenation to the brain
• Suppress cerebral metabolism
• Reduce agitation Sedation Intubation • Use of Propofol…:
Consider lipid vehicle (1.1 kcal/ mL)
• Pentobarbital:
Reduces energy requirements (76-120% REE);
Reduces protein requirements.

Narcotics: ↓
Gastric emptying = feeding intolerances • Physical and cognitive impairments affecting intake
= MALNUTRITION Nutritional Support Timing of NS = crucial
Nutritional status endangered
o ↓Impermeability to toxins
o ↑ GI absorption

Reach nutritional goals within 48-72 hours


•EN via small bowel = preferred if tolerated


High protein enteral formula to meet needs
Nutrition Assessment
Indirect calorimetry = method of choice



If not accessible:
Basal Energy Expenditure (BEE)
Harris-Benedict Equation (HBE)




Recommendation: 140 % of BEE
+ supplemental calories needed




Adequate kcal to prevent protein
sparing using high lipid content (30-40%)



Important to monitor closely to prevent : Overfeeding Underfeeding Energy Protein 1.5-2.0 g / kg/ day
minimize catabolism


**Verify Nitrogen Balance**
• Guidelines not well defined… generally increased;

Based on treatment and status

Avoid solutions containing dextrose. Fluid/ Electrolytes Zinc,
Iron,
Selenium,
Copper
Magnesium




o Antioxidants and Nutrition Modulators
o Supplementation necessary Vitamin C, D, E Vitamins and minerals Assessment Diagnosis Intervention Monitoring/ Evaluation Nutrition Care
Process • Height: 165 cm
• Weight: 127 kg
• BMI: 46,6 kg/m2 (Class III Obesity)
• Ideal Body Weight (IBW) (at BMI of approximately 25 kg/m2): 68 kg
• Adjusted Weight (ABW) : 81 kg


Medical history: Asthma

Diet history: Patient was eating regular meals.
No risk of refeeding syndrome.

Patient was intubated and mechanically vented.

Medications: Propofol (37,5 mL/h; provides 990 kcal/day),
Dilantin via PEG tube, Insulin Protocol





Estimated nutritional requirements:
• 1500-1700 kcal/day (22-25 kcal/ kg of IBW)
• 170 g protein (> 2,5 g protein/ kg of IBW) Nutrition Assessment/ Consult None provided.

“EN required to meet nutritional requirements related to current inability to swallow as evidenced by intubation and sedation and GCS of 6." 1) Enteral Nutrition (EN) via Percutaneous Endoscopic Gastroscopy(PEG)

Promote @ 20 mL/h for 8 hours.

If tolerated, increase to max of 35 mL/h for 20 hours to provide 700 kcal

Daily Total (with calories provided from Propofol): 1660 kcal + 44g protein)

2) Verify triglycerides at next blood work.

3) Hold EN feeds 2 hours pre and post Dilantin dose.

4) Vitamin protocol Patient extubated.

EN prescription changed to
Promote @ 85 mL/h x 20 hours/ day

(1700 kcal+ 106g protein per day)

Patient experienced negative nitrogen balance.
February 14th
Patient in catabolic state of brain injury February 14th Inadequate protein intake February 14th Protein powder Supplement added (quantity unknown) Verified 24h urine urea to
reassess protein needs. February 22nd Nitrogen balance=positive February 22nd February 22nd Protein requirments met 1) Protein Powder Supplement discontinued

2) EN formula changed to Isosource 1.5 @ 200 mL/hr x 7.5 hours (6 cans/ day)
= 2250 kcal +102g protein

Total daily water: 2247 mL
(1167 mL from formula+ Water Flushes 180 mL q4h)
Speech Language Pathologist Swallowing Assessment:
"Patient safe to consume regular diet and regular liquids, but needs assistance to feed due to Impulsivity."


EN stopped and tracheotomy removed.
February 23rd Monitoring Intervention Multidisciplinary Team:

• Communication is key!

o Nutritional route
o Eating difficulties
o Assessed requirements
o Weight changes/ BMI

Weekly weights until stabilization
• Energy Intake recorded until then as well



Energy requirements continue to be elevated for 1 year post TBI.

o Age
o Medications
o Activity level and weight status



Protein requirements remain very high as well (1,5 -– 2,0 g / kg/ day)
o Eventually decreases to standard 0,8 –- 1,0 g/ kg/ day


Promote intake:
o Food preferences
o Calorie Counts
o Adjusted equipment to eat

Depression (reduces appetite)
•Bowel changes


When home: Follow-up with community RD
to assure adequate diet and monitor weight. Nutritional Care After Brain Injury
(Rehabilitation) Assessment Registered Dietitian monitored P.O. intake and advancement of diet:

• Eating well. PEG tube still in place. Requires assistance at all meals, but eating complete meals.

• Patient ate moderately well; – Drowsy : Medications. Feb 24 Feb 28 Patient was transferred to Cornwall Community Hospital March 1 2011 Reviewed chart and transfer records.

Contacted attending RD at the Ottawa Hospital
Admitting Diagnosis: Head Injury

Diet Order: Regular ; No Know Allergies

Medical History: Asthma

Medications: Dilantin, Lasix, Ventolin, Trazodone, Dilaudid

Vitamin/Mineral: Folic Acid, Vitamin C, Zinc Gluconate

Labs: Serum Sodium and Potassium within normal ranges

Weight History: Height: 160 cm; Weight: 114kg
(Estimated height and weight obtained from Medical Reconciliation Forms);
BMI = 44,5 (Class III Obesity); Adjusted Body Weight (ABW)= 85kg; IBW= 56 kg

Diet History: PEG at TOH; Currently no tube feeds, but PEG still in place. Patient was very drowsy (2o Medications). Sitter reports patient eating 85-100% of meals (with assistance for set-up).
Good appetite. No Chewing or Swallowing issues (Swallowing Ax = OK!).
Functional level = low 2o Head Injury.


Estimated Nutritional Requirements:
• Energy: 1870-2300 kcal (25-28 kcal/kg @ 85 kg)
• Protein: 102-120 kcal (1,2-1,4 g/kg @ 85 kg)
• Fluid: 2000-2500 (24-30 ml/ kg)
30 yo male with adequate oral food and beverage intake related to usual good appetite as evidenced by sitter’s report of intake of close to 100% of meals. Plan:
1) Maintain regular diet (as ordered) and adjust meals to patient’s preferences (Will meet with family to discuss this issue)

2) Continue to monitor p.o. intake and follow-up.
Goal: Maintain adequate food + beverage intake to meet patient’s nutritional requirements. “(D) PEG removed March 6/ 11. Reviewed Patient’s p.o. intake with patient’s mother:

Estimated intake: 1330 kcal +58g protein + >2400 mL fluid. […]. IBW= 66kg (large frame); Adjusted Wt = 81 kg (@ 25%)

Estimated Nutrition Needs: 1782-2025 kcal/day (22-25kcal/ kg @ 81kg) + 81-97 g protein (1.1-1.2 g/ kg @ 81 kg) +2800 mL / day fluid.

Patient consuming 100% Breakfast and Supper meals; fruit, soup and milk only at Lunch 2o dislike of hot casserole meals.

(A) Plan: Maintain Regular Diet; add/ include 250 milk TID with meals; […patient’s preferences…] Add cereal and milk (125mL) at HS (pt’s usual habit is consuming HS snack). Impression: Pt will meet nutritional goals.” March 7th : Assessment by Gail, RD • Risk of skin wounds = low mobility

• Increased metabolism and muscle wasting
= low mobility + metabolic consequences of TBI.

• Patient has good kidney function (EFGR over 150)
o Little to no risk with regards to increasing protein intake to meet higher recommendations of 1,2g to 1,5g of protein per kg of IBW (81kg)
= 97g –- 121.5g per day. Assessment and Diagnosis Patient’s protein requirements increasing Increased amount of protein sources
(i.e. larger meat/egg portions)

•Requested blood work: Metabolic Panel.

Requested patient be weighed on a weekly basis. March 10th March 10th Weight: 97 kg. March 14th Severe weight loss: 16,6 kg in 2 weeks = 14,6 %
(> 3% in 2 weeks = severe).

Lab values reviewed: Serum CR and BUN= Low
• Protein + Energy Malnutrition?
Negative Nitrogen Balance?
Decreased Muscle Mass?



Estimated requirements: 2000-2268 kcal/day (25-28 kcal/kg @ 81 kg) + 121-138g protein
(1.5 –- 1.7g/kg @ 81 kg) and ~2500 mL fluids/day.





No intervention necessary: changes recently made and protein content adequate with last week's modifications to diet. March 14 Calorie Count March 22nd-24th (D) Calorie Count assessed (Average 2200 kcal + 130g protein and >2100 mL fluid,

(A) Patient meeting/ slightly exceeding estimated requirements: 2000-2268 kcal/day (25-28 kcal/kg/day @ 81 kg) + 121-138g protein (1.5 -– 1.7g/kg/day @ 81 kg) and ~2500 mL fluids/day. March 28th Weight (using bed scale) : 80 kg !! March 30th 17,5 % weight loss (SEVERE) in 1.5 weeks. March 30 ** No signs or symptoms of sever weight loss (clothes, mobility, balance).

Patient eating ad lib (extra nourishments from home). Excellent appetite. Activity level moderate. Monitor weights 2x per week and monitor intake March 30th Patient transferred to Rehabilitation at CCH while awaiting bed at ABI Clinic in Ottawa.

Showing continuous progress with SLP, Occupational Therapy and Physiotherapy March 31st : Weight: 100.5 kg! Malfunctioning scales?

• - Must wait for additional weights to determine validity of weights taken.
April 4th: N.C.P. continues…... Final Comments THANK YOU :) Questions? Physical impairments Metabolic consequences of TBI - Marieb - The Brain Trauma Foundation, 2000 - Cook et al, 2008 - Prins, M. 2008 - Cook et al, 2008 - Twyman, D 1997. - Krakau, K. et al. 2010.
- JPEN. Jan-Feb 2002
- Cook, A. et al. 2008
- Krause’s Food & Nutrition Therapy, 12th Edition. Krakau, K. et al. 2010 Cook, A. et al. 2008 JPEN, Jan-Feb 2002 Cook, A. et al. 2008 Twyman, D 1997
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