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Evidence-Based Guidelines for Traumatic Brain Injury



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B Evidence-Based Guidelines for Traumatic Brain Injury 263

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264 NUTRITION AND TRAUMATIC BRAIN INJURY TABLE B-1 Content of Evidence-Based Guidelines (EBG) for Acute Traumatic Brain Injury (TBI) in Intensive Care Unit (ICU) Setting (e.g., Critical Illness) Guideline/ Step of Care Process with Brain Trauma Foundation (BTF) Nutrition American Society for Parenteral and Enteral Nutrition Guidelines for the Management of Severe Traumatic Brain Injurya Critically Ill Patientb Implications Nutrition- A1. Traditional nutrition assessment tools (albumin, related pre-albumin, and anthropometry) are not validated in assessment critical care. Before initiation of feedings, assessment information should include evaluation of weight loss and previous nutrient intake prior to admission, level of disease severity, comorbid conditions, and function of the gastrointestinal (GI) tract. (Grade: E) C1. The target goal of enteral nutrition (EN) (defined by energy requirements) should be determined and clearly identified at the time of initiation of nutrition support therapy. (Grade: C) Energy requirements may be calculated by predictive equations or measured by indirect calorimetry. Predictive equations should be used with caution, because they provide a less accurate measure of energy requirements than indirect calorimetry in the individual patient. In the obese patient, the predictive equations are even more problematic without availability of indirect calorimetry. (Grade: E)

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265 APPENDIX B American Association of Neuroscience Nurses—Nursing Management of American Dietetic Association—Critical Illnessc Adults with Severe TBId CI: Indirect calorimetry to determine RMR Indirect calorimetry is the standard for determination of resting metabolic rate (RMR) in critically ill patients because RMR based on measurement is more accurate than estimation using predictive equations. Rating: Strong Imperative CI: RMR Predictive equations for nonobese patients If predictive equations are needed in nonobese, critically ill patients, consider using one of the following, as they have the best prediction accuracy of equations studied (listed in order of accuracy): Penn State, 2003a (79%), Swinamer (55%), and Ireton-Jones, 1992 (52%). In some individuals, errors between predicted and actual energy needs will result in under- or over-feeding. Rating: Fair Conditional CI: Inappropriate RMR predictive equations for this population The Harris-Benedict (with or without activity and stress factors), the Ireton-Jones, 1997, and the Fick equations should not be considered for use in RMR determination in critically ill patients, because these equations do not have adequate prediction accuracy. In addition, the Mifflin-St. Jeor equation should not be considered for use in critically ill patients, as it was developed for healthy people and has not been well researched in the critically ill population. Rating: Strong Imperative CI: RMR predictive equations for obese patients If predictive equations are needed for critically ill, mechanically ventilated individuals who are obese, consider using Ireton-Jones, 1992 or Penn State, 1998, because they have the best prediction accuracy of equations studied. In some individuals, errors between predicted and actual energy needs will result in under- or over-feeding. Rating: Fair Conditional CI: Rest periods and RMR Allow a rest of 30 minutes prior to RMR measurement in critically ill patients. Rating: Consensus Imperative CI: Rest period and accuracy of RMR If the critically ill patient has undergone a nursing activity or medical procedure (e.g., suctioning, wound care, central venous access or ventilator setting change), then employ a 30-minute rest after procedures to achieve a resting state during RMR measurement. Measuring RMR before the 30-minute period may be inaccurate because patient instability or ventilator gas re-equilibration. Rating: Consensus Conditional continued

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266 NUTRITION AND TRAUMATIC BRAIN INJURY TABLE B-1 Continued Guideline/ Step of Care Process with Brain Trauma Foundation (BTF) Nutrition American Society for Parenteral and Enteral Nutrition Guidelines for the Management of Severe Traumatic Brain Injurya Critically Ill Patientb Implications

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267 APPENDIX B American Association of Neuroscience Nurses—Nursing Management of American Dietetic Association—Critical Illnessc Adults with Severe TBId CI: Impact of environmental factors on RMR Ensure that the room is comfortably quiet, and the light is not providing heat or discomfort for the patient. Noise and light may cause erroneous measures of RMR if the critically ill patient’s state of rest is disturbed. Rating: Consensus Imperative CI: Impact of room temperature on RMR Recommend a room temperature 20 to 25 degrees Celsius (68 to 77 degrees Fahrenheit). When the room’s temperature is too cold, RMR is overestimated in critically ill patients by shivering or non-shivering thermogenesis, as the body adapts. Rating: Weak Imperative CI: Environmental factors and RMR Ensure that each critically ill patient is in a physically comfortable posture before proceeding with the test, because discomfort will result in erroneously high RMR measures. Make sure that repeated measures are taken in the same position to ensure comparability of data. Rating: Insufficient Evidence Imperative CI: Steady state measurement of RMR For ventilated patients, if a steady state is achieved, then a single measure is adequate to describe RMR. To achieve a steady state, discard the first five minutes of measurement. Then achieve a five-minute period with CV = 5% for oxygen consumption and carbon dioxide production. An alternate protocol can be 25 minutes in duration if a CV of 10% is achieved. If proper attention is given to achieving resting conditions, 80% or more of RMR measures in ventilator patients will be in steady state. Sedation improves the likelihood of obtaining steady state measures. Rating: Strong Imperative CI: Non-steady state measurement conditions There are published data that were not in steady state, but were still reasonably close to steady state measures. When steady state is not achieved, interpret the results carefully. If the non-steady state conditions are chronic (e.g., patient posturing), then higher measures may reflect actual energy expenditure. If non-steady state conditions are episodic (e.g., ventilator change, nursing intervention, anxiety, coughing, sneezing, movement), RMR measures should be taken at a separate time. Rating: Consensus Conditional continued

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268 NUTRITION AND TRAUMATIC BRAIN INJURY TABLE B-1 Continued Guideline/ Step of Care Process with Brain Trauma Foundation (BTF) Nutrition American Society for Parenteral and Enteral Nutrition Guidelines for the Management of Severe Traumatic Brain Injurya Critically Ill Patientb Implications Specific Level II. Patients should be fed to A2. Nutrition support therapy in the form of enteral nutrition attain full caloric replacement by nutrition (EN) should be initiated in the critically ill interventions day 7 postinjury patient who is unable to maintain volitional intake. (Grade: C) Data show that starved traumatic brain injury (TBI) patients lose sufficient A3. EN is the preferred route of feeding over nitrogen to reduce weight by 15% parenteral nutrition (PN) for the critically ill patient per week; 100 to 140% replacement who requires nutrition support therapy. (Grade: B) of Resting Metabolism Expenditure A4. Enteral feeding should be started early within the with 15 to 20% nitrogen calories first 24–48 hours following admission. (Grade: C) The reduces nitrogen loss. Data in non- feedings should be advanced toward goal over the next TBI injured patients show that a 30% 48–72 hours. (Grade: E) weight loss increased mortality rate. The data support feeding at least by A5. In the setting of hemodynamic compromise the end of the first week. It has not (patients requiring significant hemodynamic support been established that any method of including high dose catecholamine agents, alone or feeding is better than another or that in combination with large volume fluid or blood early feeding prior to 7 days improves product resuscitation to maintain cellular perfusion), outcome. Based on the level of nitrogen EN should be withheld until the patient is fully wasting documented in TBI patients resuscitated and/or stable. (Grade: E) and the nitrogen sparing effect of A6. In the ICU patient population, neither the presence feeding, it is a Level II recommendation nor absence of bowel sounds nor evidence of passage that full nutritional replacement be of flatus and stool is required for the initiation of instituted by day 7 postinjury. enteral feeding. (Grade: B) A7. Either gastric or small bowel feeding is acceptable in the ICU setting. Critically ill patients should be fed via an enteral access tube placed in the small bowel if at high risk for aspiration or after showing intolerance to gastric feeding. (Grade: C) Withholding of enteral feeding for repeated high gastric residual volumes alone may be sufficient reason to switch to small bowel feeding (the definition for high gastric residual volume is likely to vary from one hospital to the next, as determined by individual institutional protocol). (Grade: E)

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269 APPENDIX B American Association of Neuroscience Nurses—Nursing Management of American Dietetic Association—Critical Illnessc Adults with Severe TBId CI: Respiratory quotient If Respiratory Quotient (RQ) is below 0.7 or above 1.0, then repeated measures are necessary under more optimal conditions. An RQ under 0.70 suggests hypoventilation (inadequate removal of metabolic carbon dioxide from the blood to the lung) or prolonged fasting. An RQ above 1.0, in the absence of overfeeding, suggests hyperventilation (removal of carbon dioxide from the blood to the lung in excess of the amount produced by metabolism) or inaccurate gas collection. Rating: Strong Conditional CI: Enteral vs. parenteral nutrition Administering intensive insulin therapy may reduce intercranial If the critically ill ICU patient is hemodynamically stable with a pressure (ICP) (Level 3) functional GI tract, then EN is recommended over PN. Patients who received EN experienced less septic morbidity and fewer infectious Isolated patients with severe TBI complications than patients who received PN. In the critically ill treated with intensive insulin therapy patient, EN is associated with significant cost savings when compared had lower mean and maximal ICPs to PN. There is insufficient evidence to draw conclusions about the than subjects in a randomized impact of EN or PN on length of stay (LOS) and mortality. control group who were treated Rating: Strong with insulin only when their Conditional glucose levels exceeded 220 mg/ CI: Timing of enteral nutrition dl. The intensive insulin therapy If the critically ill patient is adequately fluid resuscitated, then EN group did not experience more should be started within 24 to 48 hours following injury or admission hypoglycemic episodes and required to the ICU. Early EN is associated with a reduction in infectious less vasopressors to achieve the same complications and may reduce LOS. The impact of timing of EN on cerebral perfusion pressure as the mortality has not been adequately evaluated. control group. Rating: Strong Initiating adequate nutrition within Conditional 72 hours of injury may improve CI: Immune-enhancing enteral nutrition outcomes (Level 3) Immune-enhancing EN is not recommended for routine use in critically A study of the effect of malnutrition ill patients in the ICU. Immune-enhancing EN is not associated with on rehabilitation length of stay found reduced infectious complications, LOS, reduced cost of medical care, that patients with malnutrition had days on mechanical ventilation or mortality in moderately to less lengths of stay that were 28 days severely ill ICU patients. Their use may be associated with increased longer than patients with adequate mortality in severely ill ICU patients, although adequately powered nutrition. Two systematic reviews trials evaluating this have not been conducted. For the trauma patient, found a trend toward improved it is not recommended to routinely use immune-enhancing EN, because mortality and less disability with its use is not associated with reduced mortality, reduced LOS, reduced early feeding in patients with infectious complications or fewer days on mechanical ventilation. severe TBI. The BTF Guidelines Rating: Fair for the Management of Severe TBI Imperative recommend patients be fed so that full caloric requirements are met by postinjury day 7 (Bratton et al., 2007). continued

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270 NUTRITION AND TRAUMATIC BRAIN INJURY TABLE B-1 Continued Guideline/ Step of Care Process with Brain Trauma Foundation (BTF) Nutrition American Society for Parenteral and Enteral Nutrition Guidelines for the Management of Severe Traumatic Brain Injurya Critically Ill Patientb Implications (See guideline D4 for recommendations on gastric residual volumes, identifying high-risk patients, and reducing chances for aspiration.) B1. If early EN is not feasible or available the first 7 days following admission to the ICU, no nutrition support therapy (i.e., standard therapy) should be provided. (Grade: C) In the patient who was previously healthy prior to critical illness with no evidence of protein calorie malnutrition, use of PN should be reserved and initiated only after the first 7 days of hospitalization (when EN is not available). (Grade: E) B2. If there is evidence of protein-calorie malnutrition on admission and EN is not feasible, it is appropriate to initiate PN as soon as possible following admission and adequate resuscitation. (Grade: C) B3. If a patient is expected to undergo major upper GI surgery and EN is not feasible, PN should be provided under very specific conditions: If the patient is malnourished, PN should be initiated 5–7 days preoperatively and continued into the postoperative period. (Grade: B) PN should not be initiated in the immediate postoperative period but should be delayed for 5–7 days (should EN continue not to be feasible). (Grade: B) PN therapy provided for a duration of < 5–7 days would be expected to have no outcome effect and may result in increased risk to the patient. Thus, PN should be initiated only if the duration of therapy is anticipated to be ≥ 7 days. (Grade: B) C2. Efforts to provide > 50–65% of goal calories should be made in order to achieve the clinical benefit of EN over the first week of hospitalization. (Grade: C) C3. If unable to meet energy requirements (100% of target goal calories) after 7–10 days by the enteral route alone, consider initiating supplemental PN. (Grade: E) Initiating supplemental PN prior to this 10-day period in the patient already receiving EN does not improve outcome and may be detrimental to the patient. (Grade: C)

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271 APPENDIX B American Association of Neuroscience Nurses—Nursing Management of American Dietetic Association—Critical Illnessc Adults with Severe TBId CI: Feeding tube placement Providing continuous intragastric feeding may improve tolerance EN administered into the stomach is acceptable for most critically ill (Level 3) patients. Consider placing feeding tube in the small bowel when patient is in supine position or under heavy sedation. If your institution’s Continuous feeding was better policy is to measure gastric residual volume (GRV), then consider small tolerated and achieved 75% of bowel tube feeding placement in patients who have more than 250 ml nutritional goals faster than bolus GRV or formula reflux in two consecutive measures. Small bowel tube feeding in patients admitted to a placement is associated with reduced GRV. Adequately powered studies neurosurgical ICU (20% of whom had have not been conducted to evaluate the impact of GRV on aspiration sustained a severe TBI). Feeding via pneumonia. There may be specific disease states or conditions that percutaneous endoscopic gastrostomy may warrant small bowel tube placement (e.g., fistulas, pancreatitis, in patients with moderate-to-severe gastroparesis); however, they were not evaluated at this phase of the TBI was well tolerated without analysis. complication in 97% of patients. Rating: Fair Prokinetic agents have shown no Conditional effect on feeding tolerance (Level 2) A prospective randomized double- blind study of patients with severe TBI that compared metoclopramide with normal saline found no difference in feeding intolerance or complication rates between the groups. Prokinetic agents demonstrated no improvement in feeding tolerance in patients in barbiturate-induced comas for refractory intracranial hypertension. The amount of time it took to achieve nutritional goals was not reduced with the use of prokinetic agents in a neurosurgical ICU in which 20% of patients had severe TBI. Administering intensive insulin therapy for serum glucose greater than 110 mg/dl improves outcomes (Level 2) Glucose levels exceeding 170 mg/ dl during the first 5 days post-severe TBI correlate with prolonged hospital length of stay and increased mortality. Administering intensive insulin therapy for elevated serum glucose can improve outcomes. A glucose level higher than 200 mg/dl that goes untreated during the first 24 hours post-severe TBI has been associated with worse outcomes and is related to increased ICP and impaired pupillary reaction. continued

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272 NUTRITION AND TRAUMATIC BRAIN INJURY TABLE B-1 Continued Guideline/ Step of Care Process with Brain Trauma Foundation (BTF) Nutrition American Society for Parenteral and Enteral Nutrition Guidelines for the Management of Severe Traumatic Brain Injurya Critically Ill Patientb Implications C4. Ongoing assessment of adequacy of protein provision should be performed. The use of additional modular protein supplements is a common practice, as standard enteral formulations tend to have a high nonprotein calorie:nitrogen ratio. In patients with body mass index (BMI) < 30, protein requirements should be in the range of 1.2–2.0 g/kg actual body weight per day, and may likely be even higher in burn or multi-trauma patients. (Grade: E) C5. In the critically ill obese patient, permissive underfeeding or hypocaloric feeding with EN is recommended. For all classes of obesity where BMI is > 30, the goal of the EN regimen should not exceed 60–70% of target energy requirements or 11–14 kcal/ kg actual body weight per day (or 22–25 kcal/kg ideal body weight per day). Protein should be provided in a range ≥ 2.0 g/kg ideal body weight per day for Class I and II patients (BMI 30–40), ≥ 2.5 g/kg ideal body weight per day for Class III (BMI ≥ 40). Determining energy requirements is discussed in guideline C1. (Grade: D) D1. In the ICU setting, evidence of bowel motility (resolution of clinical ileus) is not required in order to initiate EN in the ICU. (Grade: E) D3. Use of enteral feeding protocols increases the overall percentage of goal calories provided and should be implemented. (Grade: C) E1. Immune-modulating enteral formulations (supplemented with agents such as arginine, glutamine, nucleic acid, n-3 fatty acids, and antioxidants) should be used for the appropriate patient population (major elective surgery, trauma, burns, head and neck cancer, and critically ill patients on mechanical ventilation), with caution in patients with severe sepsis. (For surgical ICU patients, Grade: A) (For medical ICU patients, Grade: B) ICU patients not meeting criteria for immune-modulating formulations should receive standard enteral formulations. (Grade: B) E2. Patients with Acute respiratory distress syndrome (ARDS) and severe acute lung injury (ALI) should be placed on an enteral formulation characterized by an anti-inflammatory lipid profile (i.e., n-3 fish oils, borage oil) and antioxidants. (Grade: A) E3. To receive optimal therapeutic benefit from the immune-modulating formulations, at least 50–65% of goal energy requirements should be delivered. (Grade: C)

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273 APPENDIX B American Association of Neuroscience Nurses—Nursing Management of American Dietetic Association—Critical Illnessc Adults with Severe TBId continued

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275 APPENDIX B American Association of Neuroscience Nurses—Nursing Management of American Dietetic Association—Critical Illnessc Adults with Severe TBId CI: Blue dye use and critically ill patients Blue dye should not be added to EN for detection of aspiration. The risk of using blue dye outweighs any perceived benefit. The presence of blue dye in tracheal secretions is not a sensitive indicator for aspiration. Rating: Strong Imperative CI: Monitoring patient position Evaluating patient position should be part of an EN monitoring plan. To decrease the incidence of aspiration pneumonia and reflux of gastric contents into the esophagus and pharynx, critically ill patients should be placed in a 45-degree head of bed elevation, if not contraindicated. Rating: Strong Imperative continued

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276 NUTRITION AND TRAUMATIC BRAIN INJURY TABLE B-1 Continued Guideline/ Step of Care Process with Brain Trauma Foundation (BTF) Nutrition American Society for Parenteral and Enteral Nutrition Guidelines for the Management of Severe Traumatic Brain Injurya Critically Ill Patientb Implications Agents to promote motility such as prokinetic drugs (metoclopramide and erythromycin) or narcotic antagonists (naloxone and alvimopan) should be initiated where clinically feasible. (Grade: C) Diverting the level of feeding by post-pyloric tube placement should be considered. (Grade: C) Use of chlorhexidine mouthwash twice a day should be considered to reduce risk of ventilator-associated pneumonia. (Grade: C) D5. Blue food coloring and glucose oxidase strips, as surrogate markers for aspiration, should not be used in the critical care setting. (Grade: E) D6. Development of diarrhea associated with enteral tube feedings warrants further evaluation for etiology. (Grade: E) F2. A combination of antioxidant vitamins and trace minerals (specifically including selenium) should be provided to all critically ill patients receiving specialized nutrition therapy. (Grade: B) F3. The addition of enteral glutamine to an EN regimen (not already containing supplemental glutamine) should be considered in burn, trauma, and mixed ICU patients. (Grade: B) F4. Soluble fiber may be beneficial for the fully resuscitated, hemodynamically stable critically ill patient receiving EN who develops diarrhea. Insoluble fiber should be avoided in all critically ill patients. Both soluble and insoluble fiber should be avoided in patients at high risk for bowel ischemia or severe dysmotility. (Grade: C)

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277 APPENDIX B American Association of Neuroscience Nurses—Nursing Management of American Dietetic Association—Critical Illnessc Adults with Severe TBId CI: Monitoring gastric residual volume Evaluating GRV in critically ill patients is an optional part of a monitoring plan to assess tolerance of EN. Enteral nutrition should be held when a GRV greater than or equal to 250 ml is documented on two or more consecutive occasions. Holding EN when GRV is less than 250 ml is associated with delivery of less EN. Gastric residual volume may not be a useful tool to assess the risk of aspiration pneumonia. Adequately powered studies have not been conducted to evaluate the impact of GRV on aspiration pneumonia. Rating: Consensus Imperative CI: Monitoring and promotility agents If the patient exhibits a history of gastroparesis or repeated high GRVs, then consider the use of a promotility agent in critically ill ICU patients, if there are no contraindications. The use of a promotility agent (e.g., metoclopramide) has been associated with increased GI transit, improved feeding tolerance, improved EN delivery, and possibly reduced risk of aspiration. Rating: Strong Conditional CI: Monitoring delivery of energy Monitoring plan of critically ill patients must include a determination of daily actual EN intake. Enteral nutrition should be initiated within 48 hours of injury or admission and average intake actually delivered within the first week should be at least 60–70% of total estimated energy requirements as determined in the assessment. Provision of EN within this time frame and at this level may be associated with a decreased LOS, days on the mechanical ventilation, and infectious complications. Rating: Fair Imperative Glucose Monitoring Recommendation was removed and is under revision (Sep 2009) CI: Thermic effect of continuous feeding on RMR If a critically ill patient is continuously receiving any energy source (e.g., intravenous fluids, EN or PN), the rate and concentration should remain unchanged during the 24-hour period before and during RMR measure. After 24-hour equilibration, the impact of the thermal effect of food (TEF) on RMR is constant and indirect calorimetry measurements can proceed. Rating: Fair Conditional CI: Thermic effect of intermittent feeding on RMR If a critically ill patient receives intermittent EN above 400 kcal per feeding, then hold feedings for a minimum of five hours before measuring RMR. When a five-hour fast is not clinically feasible or when a small feeding (< 400 kcal) is given, a four-hour fast is allowed. Measuring RMR during the time of the TEF will produce inaccurately high values. Rating: Weak continued Conditional

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278 NUTRITION AND TRAUMATIC BRAIN INJURY TABLE B-1 Continued Guideline/ Step of Care Process with Brain Trauma Foundation (BTF) Nutrition American Society for Parenteral and Enteral Nutrition Guidelines for the Management of Severe Traumatic Brain Injurya Critically Ill Patientb Implications G1. If EN is not available or feasible, the need for PN therapy should be evaluated (see guidelines B1, B2, B3, C3). (Grade: C) If the patient is deemed to be a candidate for PN, steps to maximize efficacy (regarding dose, content, monitoring, and choice of supplemental additives) should be used. (Grade: C) G2. In all ICU patients receiving PN, mild permissive underfeeding should be considered at least initially. Once energy requirements are determined, 80% of these requirements should serve as the ultimate goal or dose of parenteral feeding. (Grade: C) Eventually, as the patient stabilizes, PN may be increased to meet energy requirements. (Grade: E) For obese patients (BMI ≥ 30), the dose of PN with regard to protein and caloric provision should follow the same recommendations given for EN in guideline C5. (Grade: D) G3. In the first week of hospitalization in the ICU, when PN is required and EN is not feasible, patients should be given a parenteral formulation without soy- based lipids. (Grade: D) G4. A protocol should be in place to promote moderately strict control of serum glucose when providing nutrition support therapy. (Grade: B) A range of 110–150 mg/dL may be most appropriate. (Grade: E) G5. When PN is used in the critical care setting, consideration should be given to supplementation with parenteral glutamine. (Grade: C) G6. In patients stabilized on PN, periodically repeated efforts should be made to initiate EN. As tolerance improves and the volume of EN calories delivered increases, the amount of PN calories supplied should be reduced. PN should not be terminated until ≥ 60% of target energy requirements are being delivered by the enteral route. (Grade: E) H1. Specialty high-lipid low-carbohydrate formulations designed to manipulate the respiratory quotient and reduce CO2 production are not recommended for routine use in ICU patients with acute respiratory failure. (Grade: E) (This is not to be confused with guideline E2 for ARDS/ALI). H2. Fluid-restricted calorically dense formulations should be considered for patients with acute respiratory failure. (Grade: E) H3. Serum phosphate levels should be monitored closely and replaced appropriately when needed. (Grade: E)

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279 APPENDIX B American Association of Neuroscience Nurses—Nursing Management of American Dietetic Association—Critical Illnessc Adults with Severe TBId continued

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280 NUTRITION AND TRAUMATIC BRAIN INJURY TABLE B-1 Continued Guideline/ Step of Care Process with Brain Trauma Foundation (BTF) Nutrition American Society for Parenteral and Enteral Nutrition Guidelines for the Management of Severe Traumatic Brain Injurya Critically Ill Patientb Implications (NOT including renal pancreatitis and end of life) a Brattonet al., 2007. b McClave et al., 2009. c ADA, 2006. d Mcilvoy and Meyer, 2008. TABLE B-2 Summary Table for Nutrition Content of Existing EBGs for Non-ICU Acute TBI Guidelines for the Field Management of VA Management of Concussion/Mild Guideline/Care Combat-Related Head Traumaa Traumatic Brain Injuryb Process Mild TBI-Acute Nondeployed Care; Mild (Adults, nonacute, not management of TBI Sub-Acute moderate or severe TBI) Interdisciplinary team (referrals to PT, OT, Speech & Language pathology, pharmacy, audiology/vestibular and optometry) Nutrition-related Neurobehavioral Symptom Inventory Nausea, vomiting assessment (includes nausea, change in appetite, taste Change in appetite information or smell) Change in taste or smell Patient Health Questionnaire (includes changes in appetite) Sub-Acute Cognitions (normalize nutrition) BMI > 30 (Refer for Sleep Study) Specific nutrition Novel therapy (nutritional supplements) Limit caffeine and alcohol. interventions Minimize caffeine and avoid herbal diet supplements such as “energy” products as some contain agents that cross-react with psychiatric mediation and lead to a hypertensive crisis. Novel therapy (hyperbaric oxygen, nutritional supplements) modalities in the management of concussion/ mTBI are being explored in the field as potential treatment approaches. It is the recommendation of the Working Group that interventions that lack sufficient empirical support should occur only under the auspices of an IRB-reviewed protocol. Monitoring and evaluations of nutrition-related indicators a Knuth, 2005. b Department of Veterans Affairs and Department of Defense (VA/DoD), 2009.

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281 APPENDIX B American Association of Neuroscience Nurses—Nursing Management of American Dietetic Association—Critical Illnessc Adults with Severe TBId

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282 NUTRITION AND TRAUMATIC BRAIN INJURY TABLE B-3 Questions to Guide Future Research Searches to Support Future Evidence- Based Guidelines for Nutrition in TBI Patientsa,b,c Intervention (Assessment Comparator (Alternative Population factor of interest) assessment factor) Outcome Assessment questions Acute TBI patients Selected biomarkers Other biomarkers and Sensitive and specific predictor or constellation of neuroimaging studies of the level of brain damage biomarkers (e.g., Ca2+, and oxidative stress (vs. other ROS, protein carbonyls, types of injuries or conditions) lipid peroxidase, S-100B, Or neuron specific enolase, glial fibrillary acidic Sensitive and specific predictor protein, myelin basic of mitochondrial function post protein, phosphorylated injury neurofilament H, ubiquitin C-Terminal hydrolase, a-II spectrin, microtubule- binding protein Tau, F2-isoprostane, and 4-hydroxynonenol) TBI patients Remeasurement of Monitoring weight and Maintaining optimal body energy needs at specific nutrition intake composition intervals Acute TBI patients Serum Vitamin D intake Vitamin D adequacy being considered for 25-hydroxyvitamin D progesterone treatment for TBI Treatment/intervention questions Acute TBI in ICU setting Parenteral nutrition Enteral nutrition Tight glucose control Range of control with decreased risk of hypoglycemia and accounting for risks of hypoglycemia (limits to be defined) Acute TBI in ICU setting Adjustment of nutrition Adjustment of nutrition Recovery parameters to and medication to and medication to severe TBI (e.g., intracranial maintain “tight” glucose maintain “moderate” pressure, increase the level control (e.g., 80–110 glucose control (less of consciousness, duration mg/dl) than 150 mg/dl) of ICU stay or duration of intubation) Acute TBI in ICU setting Permissive underfeeding Higher percentage of Recovery parameters (See in first 24 hours to 7 (50–80% of estimated estimated energy needs above) days energy needs using (e.g., greater than 80%) specified method to estimate energy needs)

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283 APPENDIX B TABLE B-3 Continued Intervention (Assessment Comparator (Alternative Population factor of interest) assessment factor) Outcome Acute TBI with Alternative energy Traditional sources of Minimize depressed severe reduction in sources (e.g., ketones energy (carbohydrate, mitochondrial functioning mitochondrial function from a ketogenic diet) protein, fat) using biomarkers from as shown by selected assessment (e.g., lactate biomarker levels production would indicate use of ketones) (NOTE: Only practical if assessment methods are able to identify patients with reduction in mitochondrial function—see related assessment question) Acute severe TBI injury IV n-3 fatty acid as Normal IV fat emulsion Recovery factors for severe additional or sole source (fatty acid dose TBD) TBI or research parameters of of fat (dose TBD) resolvins, protectins, tumor necrosis factor, fatty acid profile Mild TBI injury or Postoperative Normal or Resolvins, protectins, tumor repeated mild TBI injury supplemental n-3 fatty nonsupplemented diet necrosis factor acid (dose TBD) n-3 fatty acid (dose TBD) Mild TBI injury or Eucaloric ketogenic diet Normal diet (TBD) Reduce impact on repeated mild TBI injury (dose TBD) mitochondrial function (by time period, 14–30 deficit with corresponding days or 45–50 days for improvement in clinical repeated injuries) symptoms (Note: Ideally have assessment methods to measure level of mitochondrial function versus relying on clinical symptoms) Postacute phase severe Eucaloric ketogenic diet Normal diet (TBD) Reduce impact on TBI (dose TBD) mitochondrial function deficit with corresponding improvement in clinical symptoms (Note: Ideally have assessment methods to measure level of mitochondrial function versus relying on clinical symptoms) Postacute phase of either Choline supplementation Normal dietary choline Cognitive functioning mild or severe TBI (dose above Daily content (dose TBD) indicator e.g., National Recommended Intake) Institute of Child Health and Human Development combined TBI outcome statistic as well as identify potential negative side effects Postacute phase severe Creatine Nonsupplemented diet Signs and symptoms of TBI, TBI (by gender) supplementation (dose (Baseline dose TBD) e.g., reduction in headaches, TBD) fatigue, and depression and improved cognitive function as well as identifying potential negative side effects continued

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284 NUTRITION AND TRAUMATIC BRAIN INJURY TABLE B-3 Continued Intervention (Assessment Comparator (Alternative Population factor of interest) assessment factor) Outcome Postacute phase severe Preinjury creatine Preinjury Signs and symptoms of TBI, TBI supplementation nonsupplemented diet e.g., reduction in headaches, fatigue, and depression and improved cognitive function as well as identifying potential negative side effects Acute moderate to Zinc administration Zinc at optimal levels Enhanced memory, reduction severe TBI above DRI level (DRI) in depression, and anxiety (timing—e.g., hours symptoms as well as postinjury, dose and identifying potential negative duration—TBD) side effects Chronic TBI patient Various counseling Comparator counseling Optimal dietary intake theories and strategies theories and strategies matching nutrient needs (e.g., memory books, motivational interviewing, problem- solving, self-monitoring) Severe TBI with Branched-chain amino Normal amino Disability Rating Scale multiple trauma injuries, acids as % of total acid formula or Score, memory or cognitive postacute phase amino acid intake (IV nonsupplemented diet functioning or diet with varying (baseline dose TBD) amounts of leucine, isoleucine, and valine— doses TBD, duration < 1 week) TBI, chronic Novel nutrition Nonsupplemented diet Improved cognitive function therapies sold as (baseline doses TBD) (indicator TBD) as well as dietary supplements identifying potential negative (e.g., combinations of side effects resveratrol, curcumin, polyphenols, creatine and CDP-choline) Monitoring/evaluating questions TBI patients (by mild, Reassessment of energy Original RMR Significant differences between moderate, severe over needs (RMR) original RMR and reassessed specified time and event RMR intervals) TBI patients Brain-specific biomarkers Other assessment Improved brain function for improvement in biomarkers brain function a To aid those preparing future clinical practice guidelines for severe TBI, the questions have been formatted in the Population/Participant, Intervention, Comparator, Outcome (PICO) format. The questions are organized by the step in the care process to which the questions apply, i.e., assessment procedures, types of interventions to be selected, and the types of monitoring and evaluating parameters to be used. b Strauss, S. E., W. S. Richardson, P. Glasziou, and R. B. Haynes. 2005. Evidence-based medicine: How to practice and teach EBM. Edinburgh: Churchill Livingstone. c Guyatt, G., R. Drummond, M. O. Meade, and D. J. Cook, eds. 2008. Users’ guides to the medical literature: Amanual for evidence-based clinical practice, 2nd Edition. Chicago: American Medical Association.

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285 APPENDIX B REFERENCES ADA (American Dietetic Association). 2006. Critical illness evidence-based nutrition practice guideline. American Dietetic Association. http://www.adaevidencelibrary.com/topic.cfm?cat=2799 (accessed October 26, 2010). Bratton, S. L., R. M. Chestnut, J. Ghajar, F. F. McConnell Hammond, O. A. Harris, R. Hartl, G. T. Manley, A. Nemecek, D. W. Newell, G. Rosenthal, J. Schouten, L. Shutter, S. D. Timmons, J. S. Ullman, W. Videtta, J. E. Wilberger, and D. W. Wright. 2007. Guidelines for the management of severe traumatic brain injury. XII. Nutrition. Journal of Neurotrauma 24 (Suppl. 1):S77–S82. Knuth, T., P. B. Letarte, G. Ling, L. E. Moores, P. Rhee, D. Tauber, and A. Trask. 2005. Guidelines for the field management of combat-related head trauma. New York: Brain Trauma Foundation. McClave, S. A., R. G. Martindale, V. W. Vanek, M. McCarthy, P. Roberts, B. Taylor, J. B. Ochoa, L. Napolitano, and G. Cresci. 2009. Guidelines for the provision and assessment of nutrition support therapy in the adult critically ill patient: Society of Critical Care Medicine (SCCM) and American Society for Parenteral and En- teral Nutrition (A.S.P.E.N.). Journal of Parenteral and Enteral Nutrition 33(3):277–316. Mcilvoy, L., and K. Meyer. 2008. Nursing management of adults with severe traumatic brain injury. Glenview, IL: American Association of Neuroscience Nurses. VA/DoD (Department of Veterans Affairs and Department of Defense). 2009. VA/DoD clinical practice guideline for management of concussion/mild traumatic brain injury. http://www.healthquality.va.gov/mtbi/concus- sion_mtbi_full_1_0.pdf (accessed January 19, 2011).