[Analysis of energy balance and risk factors on clinical outcomes in patients with severe traumatic brain injury].

OBJECTIVE: To observe the energy expenditure in severe traumatic brain injury patients, and to assess the impact of cumulative energy balance on clinical outcomes. METHODS: Using prospective self-controlled study, the change in energy expenditure of 42 patients with severe traumatic brain injury was measured by indirect calorimetry (IC). Daily energy intake was recorded. Afterwards, energy balance was calculated. The levels of nutritional biochemical indicators were compared. Logistic regression analysis was used to analyze the correlation of cumulative energy balance with clinical outcomes. RESULTS: Mean practical energy intake of all patients was (6787 ± 1848) kJ/d, and mean negative energy balance was (913 ± 285) kJ/d. The negative energy balance was most crucial in first 3 days after admission. Meanwhile, practical energy intake was significantly lower than target energy intake (kJ: 2859 ± 1370 vs. 6027 ± 899, P < 0.01). The practical energy intake was increased with time, and it was found that the first 14 days were crucial for development of negative energy balance. On 7th day after admission, albumin (g/L) level in plasma was lowest compared with that on 3rd day (29.5 ± 5.0 vs. 35.9 ± 3.8, P < 0.01), and then it was increased gradually returning to normal level on 28 days (34.1 ± 2.8). Three days after admission, prealbumin (mg/L: 122.5 ± 23.3) was obviously lower than normal level, but it rapidly elevated on 7th day (214.3 ± 38.6, P < 0.01) and continued to rise till 28th day (257.7 ± 25.2). On the 3rd day after admission, C-reactive protein (mg/L: 139.5 ± 54.4) was obviously higher than normal level. However, it significantly fell on 7th day (108.4 ± 42.2, P < 0.01), and it continued to fall. Logistic regression analysis showed a strong association of cumulative negative energy balance with infection and upper gastrointestinal bleeding [odds ratio (OR) of infection was 2.130, 95% confidence interval (95%CI) 1.540 to 29.661, P = 0.023; OR of upper gastrointestinal bleeding was 0.083, 95%CI 0.013 to 0.542, P = 0.009]. CONCLUSIONS: Cumulative negative energy balance may be correlated with the occurrence of complications in patients with severe traumatic brain injury. On the basis of the measurements of changes in energy by IC, early supply of sufficient energy may improve the outcome of patients.

[Comparison of measuring energy expenditure with indirect calorimetry and traditional estimation of energy expenditure in patients in intensive care unit].

OBJECTIVE: To compare measurement of energy expenditure (MEE) by indirect calorimetry (IC) with traditional estimation of energy expenditure (EEE), to provide a basis for energy supplementary for critically ill patients. METHODS: Using self-controlled study,the energy expenditure of 57 intensive care unit (ICU) patients was measured by IC. Meanwhile, EEE was also calculated using the following equations : Harris-Benedict (HB), HB×factor , or 104.6 kJ/kg. Body weight were calculated using actual body weight (ABW) or ideal body weight (IBW). If body mass index (BMI)<18.4 kg/m(2) it was considered as underweight , and the IBW was selected from the IBW table. The potential adequacy of estimated energy was assayed by ratio of EEE/MEE. RESULTS: There was significant difference in MEE by IC and EEE by HB, HB×factor and 104.6 kJ/kg [(6 335 ± 1 004) kJ, (9 125 ± 1 795) kJ, (7 188 ± 1 029) kJ vs. (7 753 ± 1 439) kJ ,P<0.05 or P<0.01]. There was significant difference between EEE by HB×factor and 104.6 kJ/kg (P<0.01) , and EEE by 104.6 kJ/kg×ABW , and the latter was closer to MEE. Underfeeding would occur in most ICU patients if HB equation was used [100% (4/4) in underweight patients and 73.59% (39/53) in normal weight (BMI 18.5-23.9 kg/m(2))]. EEE as calculated by 104.6 kJ/kg×IBW was reasonable in the underweight patients 100% ( 4/4 ), but EEE in the patients with normal weight by using HB×factor or 104.6 kJ/kg×ABW resulted in significant underfeeding [39.62% (21/53) and 43.39% (23/53)] or overfeeding [24.53% (13/53) and 13.22% (7/53)]. CONCLUSION: EEE derived from the equations was extremely inaccurate and may result in significant underfeeding or overfeeding in individuals. On the basis of this study we would recommend IC for measuring energy expenditure in ICU patients. Otherwise , the equations of 104.6 kJ/kg×IBW in underweight and 104.6 kJ/kg×ABW in normal weight patients may be reasonable.

[Effects of early supplemental parenteral nutrition on nutrition intakes and clinical outcomes in trauma patients].

OBJECTIVE: To evaluate energy and protein intake changes in early supplemental parenteral nutrition (PN) in trauma patients, and to assess its impact on clinical outcomes. METHODS: Clinical results of patients receiving or not receiving additional PN during the first 7 days after injury were retrospectively analyzed, with a total of 195 patients classified into two groups: control group (n=105) and mixed nutrition group (n=90). The time of nutrition support, intakes of protein and energy within 14 days after trauma, and clinical outcomes were compared between two groups. RESULTS: The degree of injury was comparable between two groups with no significant differences in acute physiology and chronic health evaluation II score, injury severity score (ISS) and Glasgow coma score (GCS). Compared with the control group, the mixed nutrition group received parenteral nutritional support earlier (40.0±21.0 hours vs. 55.1±23.5 hours, P<0.01), with later beginning of enteral nutrition (EN, 75.2±54.5 hours vs. 55.1±23.5 hours, P<0.01) and lower rate of EN in 48 hours after admission [14.4% (13/90) vs. 43.8% (46/105), P<0.01]. The time of restoring oral diet was not different between the mixed nutrition group and control group (10.8±3.7 days vs. 11.4±3.6 days, P>0.05). The energy intake was significantly higher in the mixed nutrition group than in the control group in 3, 7, 14 days (3 days: 3981.6±2209.3 kJ vs. 2683.2±1414.9 kJ, 7 days: 5477.5±2008.4 kJ vs. 3619.1±1429.9 kJ, 14 days: 6250.2±2533.2 kJ vs. 5199.9±1972.7 kJ, P<0.05 or P<0.01). In both groups the protein intake was insufficient, and it was significantly lower in the mixed nutrition group than in the control group on day 3 (20.6±18.4 g vs. 26.5±13.8 g, P<0.05). The patients in the mixed nutrition group had longer hospital stay time (73.9±62.5 days vs. 50.9±33.3 days, P<0.01). The mortality rate of mixed nutrition group and control group was 4.4% (4/90) and 3.8% (4/105) respectively, the rate of infection and acute respiratory distress syndrome (ARDS) were 8.9% (8/90) and 3.8% (4/105), 5.6% (5/90) and 7.6% (8/105) respectively, duration of mechanical ventilation (days) was 8.3±4.6 and 7.3±4.7, duration of stay in ICU was 17.6±13.2 days and 14.2±11.3 days respectively, and no significant difference was found between two groups (all P>0.05). CONCLUSION: Although early supplemental PN within 7 days after injury increases energy intake, PN without a standard protocol does not improve clinical outcomes and may prolong hospital stay time.