- Email: [email protected]
Enteral tube feeding in a patient with traumatic brain injury
116
Enteral Tube Feeding in a Patient With Traumatic Brain Injury Martin K. Kiel, MD ABSTRACT. Kiel MK. Enter-al tube feeding in a patient with traumatic brain injury. Arch Phys Med Rehabil 1994;75:116-7. a Tube feeding is frequently needed for patients with severe traumatic brain injury. When the patient is on the rehabilitation unit, bolus type feeding by gastrostomy tube is more easily accomplished than continuous type feeding by jejunostomy tube (J-tube). In the case presented here, the patient received less calories via J-tube feeds while he was on the rehabilitation unit than when he was in the intensive care unit or the neurosurgicai unit. This has implications for the trauma team, which initially decides the type of nutritional support. 0 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehubilitation
Tube feeding is often required for patients with severe traumatic brain injury (TBI). This may be done with a nasal gastric tube, nasoduodenal tube, gastrostomy or jejunostomy tube. When the patient is admitted to the intensive care unit (ICU), frequently a nasoenteric tube is used, and then if the injury is severe, a gastrostomy or jejunostomy feeding tube is used. When the patient is transferred from ICU to a neurosurgical ward, tube feeds may still be required. During this time, physical therapy, occupational therapy, and speech therapy are usually underway; however, the patient spends most of his or her time on the neurosurgical ward and there is only minimal need to interrupt his or her feeds for therapies. This situation changes once the patient is transferred to the rehabilitation unit. He or she must be out of bed and out of his or her room for the majority of the day. This is not compatible with adequate continuous tube feedings; hence, the physiatrist usually tries to switch the feeds to bolus type. In the case presented here, the patient arrived on the rehabilitation unit receiving continuous jejunostomy tube feedings. Frequent interruptions of the feeds were required due to the nature of the rehabilitation program. Initially attempts were made to use small frequent bolus J-tube feeds (100 to 15Occ), but these were not tolerated and the patient’s calorie intake declined. Ultimately a percutaneous endoscopic gastrostomy tube was placed. The author believes that peg or gastrostomy tube feeds are better suited for the rehabilitation setting than J-tube feeds, which must be continuous. This could be of importance to the trauma team, which makes the initial decision regarding nutritional support. CASE HISTORY The patient, a 17-year-old boy, sustained a traumatic brain injury from a bull-riding accident on April 14, 1991. On admission, he From the Department of Physical Medicine and Rehabilitation, Washoe Medical Center, Rena, NV. Submitted for publication October 19, 1992. Accepted in revised form February 25, 1993. Reprint requests to Martin K. Kiel, MD, 50 Kirman, Suite 201, Rena, NV 89502. No commercial party having a direct or indirect interest in the subject matter of this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. 8 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/94/7501-0025$3.00/O
Arch Phys Med Rehabil Vol75,
January lS94
was lethargic, confused, and moved all limbs spontaneously. Computed tomography of the head from April 16, 199 1 reported hemorrhage in the left frontal and temporal lobes. Nasogastric feedings were started on April 1.5, 1991. A feeding jejunostomy was placed April 29, 1991. The patient was transferred to the rehabilitation unit on May 15, 1991, and he was alert and oriented to place and standing with moderate assistance. On May 20, 1991, a modified barium swallow study showed some aspiration. Jejunostomy feedings were continued, but it was difficult to maintain continuous feedings. The patient was agitated and was placed in a Craig bed. Small bolus Jtube feedings were tried, but the patient developed vomiting. Oral feedings were started on May 30, 1991. The patient was evaluated by an ears, nose, throat specialist, who found multiple cranial nerve abnormalities affecting swallowing, namely the ninth, tenth, 1 lth, and 12th on the left and the tenth on the right. A repeat modified barium swallow did not show any cricopharyngeal spasm. On June 12, 1991 the gastrointestinal (GI) service placed a peg tube and the J-tube was discontinued because it was not providing adequate nutrition. During the procedure, upper endoscopy was normal. Initially, bolus peg feedings with 35Occ of Ensure” every 6 hours was tried. The patient was also taking some oral feedings. Still there was some vomiting and the peg feedings were changed to continuous feedings of 12%~ per hour for 10 hours through the night. Gradually his oral intake improved. On June 29, 1991 a modified barium swallow was repeated and showed improvement. From July 23, 1991 until his discharge on August 8, 1991, it was possible to hold most of the tube feedings because his oral intake was significantly improved. There still were occasional episodes of vomiting. An upper GI barium study and small bowel follow through were normal, no gastric outlet obstruction was found. The patient was discharged on August 8, 1991 to a Transitional Living Center. METHODS This retrospective
study reviewed
the patient’s
hospital
chart. A dietitian calculated the patient’s intake from the amount of tube feed plus oral feeding. The tube feeds included, at various times, Ultra-Cal,b Impact,” and Ensure. The oral diet included dysphagia diets (pureed-type foods and thickened liquids, etc) and mechanical soft and regulartype diet. These diets were estimated to provide approximately 2,lOOkcal per day. The amount of the meal eaten was estimated either by the dietitian or by the nursing staff.
117
TUBE FEED IN TBI, Kiel
If there was vomiting or incomplete data on the percentage of oral intake, these days were not included in the assessment of nutrition intake. The patient’s body weight was monitored throughout the hospital course. His total length of stay was 118 days and body weights were obtained on 49 days. Serum albumin was also monitored and was obtained on 14 days. RESULTS While the patient was in the ICU, the average calorie intake per day received by J-tube feedings was 2,Ollkcal. When the patient was transferred to the neurosurgical ward, the average calorie intake per day by J-tube was 2,4OOkilocalories. When the patient was transferred to the rehabilitation unit, he was exclusively on J-tube feeds for the first 11 days, and averaged only 1,418kilocalories per day. Oral feedings were begun on June 5,199l. The J-tube was continued until June 13, 1991, and was then replaced with the peg feeding tube. Oral intake improved. The average oral intake while the patient had the J-tube was only 79kilocalories per day. The average oral intake when the patient had the peg feeding tube was 1,036kilocalories per day. It was not possible to compare J-tube intake with peg tube intake, because the patient’s oral intake was gradually improving. The patient’s body weight was 63.5kg when he was admitted to the ICU. His weight dropped to 58.5kg before being transferred to the rehabilitation unit. Midway through his stay on the rehabilitation unit, his weight was 54kg, and at the time of discharge, he weighed 52kg. His serum albumin was also periodically monitored. At the time of his admission to the ICU, it was 2.9gm/dL. Just before entering the rehabilitation unit, it was 3.lgnNL. Midway through his stay, it was 3.6gm/dL, and at discharge it was 4.3gm/dL.
bolus feeds are more compatible with this than continuous feeds. When the patient was on peg tube feeds, he also was receiving oral intake, so direct comparison of calorie intake between the two types of tube feeds was not possible. We did find, however, that the patient received less calories via J-tube feeds while on the rehabilitation unit than when he was in the ICU or the neurosurgical unit, and we propose that this was due to the nature of the rehabilitation program, which necessitates frequent out-of-room activities, with the attendant difficulty of maintaining constant infusion system. When the trauma patient is initially admitted, the trauma team decides which is the most appropriate method of nutritional support. If tube feeds will be required for an extended period of time (for example, beyond 4 to 6 weeks), a more permanent enteral feeding tube is used. This may be a gastrostomy tube, a jejunostomy tube or a combined tube placed through a gastrostomy stoma with one tube in the stomach and the other in the jejunum. Some factors that a trauma team considers in deciding which is the most appropriate method are (1) feedings can be started sooner with the jejunostomy tube because the small bowel returns to function sooner than the stomach’; (2) there is less chance for gastroesophageal reflux and aspiration with the jejunostomy tube’; (3) consideration of the simplest procedure with the least morbidity; and (4) the method that minimizes potential errors in the administration of the feeds. Another factor that we believe should be taken into account is the patient’s potential need for a comprehensive medical rehabilitation program. Acknowledgments:I thank Fran Poe, MPH, RD, clinical dietitian, for her assistance in gathering data for this article.
DISCUSSION
References 1. Sajar S, Harland P, Shield R. Early postoperative feeding with elemental diet. B Med J 1979;66:727-32. 2. Ryan JA, Page LP. Intrajejunol feeding: development and current status. J Parenta Enter Nutr 1984;S: 187-98.
We attempted to determine if the patient received better nutritional support with the peg feeding tube than the jejunostomy feeding tube while he was on the rehabilitation unit. Bolus feeds are tolerated in the stomach, but not the jejunum. The rehabilitation program requires the patient to participate in a variety of therapies outside his room and
Suppliers a. Ensure, Ross Laboratories, Division of Abbott Laboratories. Columbus. OH 43216. b. Ultra-Cal, Mead Johnson Enteral Nutritionals, Bristol-Myers Squibb Comuanv. 9017 Meadowfoam Court. Elk Grove. CA 95758. c. Impact, bandoz Nutrition Corporation, 5320 West 23rd Street, PO Box 370, Minneapolis, MN 55440.
Arch Phya Mod hhabil
Vol75, Jammy 1994
Enteral Tube Feeding in a Patient With Traumatic Brain Injury Martin K. Kiel, MD ABSTRACT. Kiel MK. Enter-al tube feeding in a patient with traumatic brain injury. Arch Phys Med Rehabil 1994;75:116-7. a Tube feeding is frequently needed for patients with severe traumatic brain injury. When the patient is on the rehabilitation unit, bolus type feeding by gastrostomy tube is more easily accomplished than continuous type feeding by jejunostomy tube (J-tube). In the case presented here, the patient received less calories via J-tube feeds while he was on the rehabilitation unit than when he was in the intensive care unit or the neurosurgicai unit. This has implications for the trauma team, which initially decides the type of nutritional support. 0 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehubilitation
Tube feeding is often required for patients with severe traumatic brain injury (TBI). This may be done with a nasal gastric tube, nasoduodenal tube, gastrostomy or jejunostomy tube. When the patient is admitted to the intensive care unit (ICU), frequently a nasoenteric tube is used, and then if the injury is severe, a gastrostomy or jejunostomy feeding tube is used. When the patient is transferred from ICU to a neurosurgical ward, tube feeds may still be required. During this time, physical therapy, occupational therapy, and speech therapy are usually underway; however, the patient spends most of his or her time on the neurosurgical ward and there is only minimal need to interrupt his or her feeds for therapies. This situation changes once the patient is transferred to the rehabilitation unit. He or she must be out of bed and out of his or her room for the majority of the day. This is not compatible with adequate continuous tube feedings; hence, the physiatrist usually tries to switch the feeds to bolus type. In the case presented here, the patient arrived on the rehabilitation unit receiving continuous jejunostomy tube feedings. Frequent interruptions of the feeds were required due to the nature of the rehabilitation program. Initially attempts were made to use small frequent bolus J-tube feeds (100 to 15Occ), but these were not tolerated and the patient’s calorie intake declined. Ultimately a percutaneous endoscopic gastrostomy tube was placed. The author believes that peg or gastrostomy tube feeds are better suited for the rehabilitation setting than J-tube feeds, which must be continuous. This could be of importance to the trauma team, which makes the initial decision regarding nutritional support. CASE HISTORY The patient, a 17-year-old boy, sustained a traumatic brain injury from a bull-riding accident on April 14, 1991. On admission, he From the Department of Physical Medicine and Rehabilitation, Washoe Medical Center, Rena, NV. Submitted for publication October 19, 1992. Accepted in revised form February 25, 1993. Reprint requests to Martin K. Kiel, MD, 50 Kirman, Suite 201, Rena, NV 89502. No commercial party having a direct or indirect interest in the subject matter of this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. 8 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation 0003-9993/94/7501-0025$3.00/O
Arch Phys Med Rehabil Vol75,
January lS94
was lethargic, confused, and moved all limbs spontaneously. Computed tomography of the head from April 16, 199 1 reported hemorrhage in the left frontal and temporal lobes. Nasogastric feedings were started on April 1.5, 1991. A feeding jejunostomy was placed April 29, 1991. The patient was transferred to the rehabilitation unit on May 15, 1991, and he was alert and oriented to place and standing with moderate assistance. On May 20, 1991, a modified barium swallow study showed some aspiration. Jejunostomy feedings were continued, but it was difficult to maintain continuous feedings. The patient was agitated and was placed in a Craig bed. Small bolus Jtube feedings were tried, but the patient developed vomiting. Oral feedings were started on May 30, 1991. The patient was evaluated by an ears, nose, throat specialist, who found multiple cranial nerve abnormalities affecting swallowing, namely the ninth, tenth, 1 lth, and 12th on the left and the tenth on the right. A repeat modified barium swallow did not show any cricopharyngeal spasm. On June 12, 1991 the gastrointestinal (GI) service placed a peg tube and the J-tube was discontinued because it was not providing adequate nutrition. During the procedure, upper endoscopy was normal. Initially, bolus peg feedings with 35Occ of Ensure” every 6 hours was tried. The patient was also taking some oral feedings. Still there was some vomiting and the peg feedings were changed to continuous feedings of 12%~ per hour for 10 hours through the night. Gradually his oral intake improved. On June 29, 1991 a modified barium swallow was repeated and showed improvement. From July 23, 1991 until his discharge on August 8, 1991, it was possible to hold most of the tube feedings because his oral intake was significantly improved. There still were occasional episodes of vomiting. An upper GI barium study and small bowel follow through were normal, no gastric outlet obstruction was found. The patient was discharged on August 8, 1991 to a Transitional Living Center. METHODS This retrospective
study reviewed
the patient’s
hospital
chart. A dietitian calculated the patient’s intake from the amount of tube feed plus oral feeding. The tube feeds included, at various times, Ultra-Cal,b Impact,” and Ensure. The oral diet included dysphagia diets (pureed-type foods and thickened liquids, etc) and mechanical soft and regulartype diet. These diets were estimated to provide approximately 2,lOOkcal per day. The amount of the meal eaten was estimated either by the dietitian or by the nursing staff.
117
TUBE FEED IN TBI, Kiel
If there was vomiting or incomplete data on the percentage of oral intake, these days were not included in the assessment of nutrition intake. The patient’s body weight was monitored throughout the hospital course. His total length of stay was 118 days and body weights were obtained on 49 days. Serum albumin was also monitored and was obtained on 14 days. RESULTS While the patient was in the ICU, the average calorie intake per day received by J-tube feedings was 2,Ollkcal. When the patient was transferred to the neurosurgical ward, the average calorie intake per day by J-tube was 2,4OOkilocalories. When the patient was transferred to the rehabilitation unit, he was exclusively on J-tube feeds for the first 11 days, and averaged only 1,418kilocalories per day. Oral feedings were begun on June 5,199l. The J-tube was continued until June 13, 1991, and was then replaced with the peg feeding tube. Oral intake improved. The average oral intake while the patient had the J-tube was only 79kilocalories per day. The average oral intake when the patient had the peg feeding tube was 1,036kilocalories per day. It was not possible to compare J-tube intake with peg tube intake, because the patient’s oral intake was gradually improving. The patient’s body weight was 63.5kg when he was admitted to the ICU. His weight dropped to 58.5kg before being transferred to the rehabilitation unit. Midway through his stay on the rehabilitation unit, his weight was 54kg, and at the time of discharge, he weighed 52kg. His serum albumin was also periodically monitored. At the time of his admission to the ICU, it was 2.9gm/dL. Just before entering the rehabilitation unit, it was 3.lgnNL. Midway through his stay, it was 3.6gm/dL, and at discharge it was 4.3gm/dL.
bolus feeds are more compatible with this than continuous feeds. When the patient was on peg tube feeds, he also was receiving oral intake, so direct comparison of calorie intake between the two types of tube feeds was not possible. We did find, however, that the patient received less calories via J-tube feeds while on the rehabilitation unit than when he was in the ICU or the neurosurgical unit, and we propose that this was due to the nature of the rehabilitation program, which necessitates frequent out-of-room activities, with the attendant difficulty of maintaining constant infusion system. When the trauma patient is initially admitted, the trauma team decides which is the most appropriate method of nutritional support. If tube feeds will be required for an extended period of time (for example, beyond 4 to 6 weeks), a more permanent enteral feeding tube is used. This may be a gastrostomy tube, a jejunostomy tube or a combined tube placed through a gastrostomy stoma with one tube in the stomach and the other in the jejunum. Some factors that a trauma team considers in deciding which is the most appropriate method are (1) feedings can be started sooner with the jejunostomy tube because the small bowel returns to function sooner than the stomach’; (2) there is less chance for gastroesophageal reflux and aspiration with the jejunostomy tube’; (3) consideration of the simplest procedure with the least morbidity; and (4) the method that minimizes potential errors in the administration of the feeds. Another factor that we believe should be taken into account is the patient’s potential need for a comprehensive medical rehabilitation program. Acknowledgments:I thank Fran Poe, MPH, RD, clinical dietitian, for her assistance in gathering data for this article.
DISCUSSION
References 1. Sajar S, Harland P, Shield R. Early postoperative feeding with elemental diet. B Med J 1979;66:727-32. 2. Ryan JA, Page LP. Intrajejunol feeding: development and current status. J Parenta Enter Nutr 1984;S: 187-98.
We attempted to determine if the patient received better nutritional support with the peg feeding tube than the jejunostomy feeding tube while he was on the rehabilitation unit. Bolus feeds are tolerated in the stomach, but not the jejunum. The rehabilitation program requires the patient to participate in a variety of therapies outside his room and
Suppliers a. Ensure, Ross Laboratories, Division of Abbott Laboratories. Columbus. OH 43216. b. Ultra-Cal, Mead Johnson Enteral Nutritionals, Bristol-Myers Squibb Comuanv. 9017 Meadowfoam Court. Elk Grove. CA 95758. c. Impact, bandoz Nutrition Corporation, 5320 West 23rd Street, PO Box 370, Minneapolis, MN 55440.
Arch Phya Mod hhabil
Vol75, Jammy 1994