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Routine intragastric feeding following traumatic brain injury is safe and well tolerated
SCIENTIFIC PAPERS
Routine Intragastric Feeding Following Traumatic Brain Injury Is Safe and Well Tolerated Charles T. Klodell, MD, Michelle Carroll, RN, BSN, Eddy H. Carrillo, MD, David A. Spain, MD, Louisville, Kentucky
BACKGROUND: Delayed gastric emptying following traumatic brain injury (TBI) has led some to advocate jejunal feeding. Our purpose was to review our experience with percutaneous endoscopic gastrostomy (PEG) and intragastric feeding in TBI patients to assess safety and effectiveness. METHODS: All patients on a TBI clinical pathway at our institution were targeted for early PEG. After PEG, standard enteral nutrition was initiated. Abdominal examination and gastric residual volumes were used to assess tolerance. RESULTS: There were 118 patients with moderate to severe TBI. The average age was 36 years. Mean Injury Severity Score (ISS) was 25. Enteral access was obtained and intragastric feeding was initiated on day 3.6. Intragastric feeding was tolerated without complication in 111 of 114 (97%) patients. Five patients aspirated, but had no evidence of intolerance prior to the event. CONCLUSIONS: PEG provided reliable enteral access in moderate to severe TBI patients. Intragastric feeding was well tolerated with a low complication rate (4%). Am J Surg. 2000;179: 168 –171. © 2000 by Excerpta Medica, Inc.
T
raumatic brain injury (TBI) continues to be a leading cause of morbidity and mortality in trauma patients. Early and adequate nutrition plays a crucial role in improving outcome.1–3 In a variety of patient populations, the enteral route for this early nutritional support has yielded superior results.2,4 –9 Even though the necessity of enteral access is widely accepted, the best method remains controversial. There have been reports of
From the Department of Surgery, University of Louisville School of Medicine (CTK, EHC, DAS), the Trauma Program in Surgery (EHC, DAS), University of Louisville Hospital (MC), and the Veterans Affairs Medical Center (DAS), Louisville, Kentucky. Presented as a poster at the 28th Educational and Scientific Symposium of the Society of Critical Care Medicine, San Francisco, California, January 24 –26, 1999. Requests for reprints should be addressed to David A. Spain, MD, Department of Surgery, University of Louisville, Louisville, Kentucky 40292. Manuscript submitted November 10, 1999, and accepted in revised form January 27, 2000.
168
© 2000 by Excerpta Medica, Inc. All rights reserved.
delayed gastric emptying following TBI and subsequent concern over the use of gastric feeding.10 –12 Saxe et al13 documented decreased pressure of the lower esophageal sphincter in an array of patients with neurological injuries. Many are opposed to gastric feeding in TBI because of these claims of decreased lower esophageal sphincter tone and poor gastric emptying. We attempt to demonstrate the safety and efficacy of gastric feeding in TBI patients. For these reasons, the placement of a jejunostomy tube has been touted superior to a gastrostomy tube, with claims of lower rates of pulmonary aspiration and better tolerance of feedings.1,13 Yet, others claim that smaller, softer, and longer nasoenteric feeding tubes that can be advanced into the proximal jejunum are preferred. Unfortunately, frequent dislodgment, obstruction of the lumen, and the cumbersome and time-consuming maneuvers to correctly place these tubes may limit their clinical usefulness.14 Some physicians favor the placement of transpyloric feeding tubes, citing lower complication rates. Spain et al15 noted that transpyloric passage had no effect on the time required to achieve full feeding, number of days on a ventilator, length of stay in the intensive care unit (ICU), pneumonia, aspiration, or mortality. Multiple studies in non-TBI patients have documented comparable rates of aspiration as well as complications associated with gastric and jejunal feeding tubes.15–19 Additionally, it has been shown that jejunal feeding tubes increased gastric output even in the absence of reflux.20 Gastrostomy tubes may also have an advantage because they do not cross the gastroesophageal junction, thus stenting it open. With these factors in mind, reevaluation of the method of enteral access in TBI patients is warranted. Bedside percutaneous endoscopic gastrostomy (PEG) is a safe and effective method of providing access to the gastrointestinal tract for nutritional support. In patients with significant TBI, this procedure can be safely performed in the ICU without secondary insult to the brain or untoward complications.14 At our institution, we have developed a clinical pathway for the management of TBI patients. This pathway utilizes a multidisciplinary approach for the total care of TBI patients and sets target dates for tracheostomy and PEG tube placement by postinjury day 4. This pathway has been prospectively studied and shown to expedite the disposition and rehabilitation of TBI patients without a negative impact on their overall care or recovery.21 Therefore, we undertook this study in an effort to delineate whether routine use of intragastric enteral nutrition is safe and effective in patients with TBI. 0002-9610/00/$–see front matter PII S0002-9610(00)00297-X
ROUTINE INTRAGASTRIC FEEDING AFTER TRAUMATIC BRAIN INJURY/KLODELL ET AL
TABLE Demographic Information Total patients Gender (men/women) Mean age (range) Mean ISS on admission (range) Mean NGT output (range)*
118 80/38 36 (15 to 83) 25 (9 to 43) 400 mL (0 to 1850 mL)
* Output was measured in the 24 hours before enteral feeding. ISS ⫽ Injury Severity Score; NGT ⫽ nasogastric tube.
PATIENTS AND METHODS We retrospectively reviewed the medical records of 118 moderate (Glasgow Coma Score [GCS] 8 to 12) to severe (GCS ⬍ 8) TBI patients admitted to our academic level I trauma center over a 3-year period (1996 to 1999) and who were placed on TBI pathways. The records were reviewed for demographic data, injury severity, and nasogastric tube outputs before enteral access as well as tolerance of enteral nutrition. All patients were in an ICU at initiation of feeding, and tolerance of tube feeds was evaluated every 4 hours based on gastric residuals as well as an abdominal examination.22 As part of the protocol for enteral feeding, all patients were fed in a 30-degree upright position, and feedings were administered as a continuous drip by a mechanical pump. Predictive equations were utilized to calculate basal energy expenditure and caloric goals. Substrate targets were set at 55% to 60% carbohydrate, 20% protein, and 20% to 25% fat. Our standard formula has this allocation of substrate, as well as added fiber. Typically, the initial rate was 25 mL per hour and was subsequently increased by 25 mL per hour every 8 to 12 hours, until the goal rate was reached. Tracheal secretions were routinely checked for tube feed dye. Gastric residual volume was checked every 8 hours, and tube feedings were stopped when gastric residual volume exceeded 200 mL. Tube feedings were then reinitiated at the previous rate when gastric volume lowered to less than 200 mL at the next measurement. Food coloring was added to all feedings, and aspiration was defined as retrieval of colored aspirate from the tracheobronchial tract, whether or not consequences were noted on chest roentgenograms. In nearly 50% of cases, prokinetics were initiated concurrently with enteral nutrition. Metacloperamide was used most commonly, although cisapride was chosen occasionally. In most cases, these agents were withdrawn after 48 hours, and their ongoing use was contingent on the response to discontinuance.
RESULTS There were 80 men and 38 women whose average age was 36 years (range 15 to 83). The mean ISS was 25 (range 9 to 43; Table). There were 89 patients with severe TBI (GCS⬍8) and 29 patients with moderate TBI (GCS ⫽ 8 to 12). On average, enteral access was obtained and gastric feeding instituted within 3.6 days of hospital admission. Thirteen patients received enteral nutrition on postinjury day 1. More than 80% of the patients received a PEG tube for initial enteral access, and the remainder received a small-bore nasogastric tube. The Dobhoff tube was used only in patients with extremely elevated intracranial pres-
sures. Traumatic brain injuries did not delay initiation of enteral nutrition. Ultimately, PEG tubes were placed in 97% (114 of 118) of patients. No complications related to the gastrostomy tube placement occurred. Four patients recovered rapidly from their TBI and were able to have the nasogastric feeding tube removed. The mean nasogastric tube output in the 24 hours before enteral feeding was 400 mL. Overall, 111 of 114 (97%) TBI patients were able to tolerate intragastric nutrition. Two patients required endoscopic conversion to combination gastrostomy-jejunostomy tubes, related to gastroparesis and high gastric residuals. No single factor was predictive of the patients who required conversion to jejunal tubes, and both patients subsequently tolerated jejunal feedings. A third patient was taken to the operating room for unrelated reasons, and a jejunostomy tube was placed during laparotomy. No patient required conversion to parenteral nutrition. Of the 97% of patients who tolerated gastric nutrition, 77% (85 of 111) of the patients were at the goal rate by the fourth day of nutritional support. Many patients (37 of 111) were able to reach the goal rate within 48 hours. Five patients (4%) were noted to have aspiration related to initiation of enteral nutrition and subsequently developed pneumonia; 4 of these patients had PEG tubes at the time of the aspiration event. Neither nasogastric outputs nor gastric residuals were predictive of which patients would aspirate, with average gastric residuals of ⬍100 mL in this subset. All 5 patients tolerated subsequent gastric feeding without further incidents.
COMMENTS The benefits of early nutritional support in TBI patients are well known. The preference for enteral nutrition, as opposed to parenteral, is also nearly universal. However, controversy still remains regarding the route of administration. Some physicians advocate the use of nasogastric feeding tubes. These tubes are easily placed and are relatively inexpensive, but they suffer from frequent dislodgment that interrupts nutrition. They also pose the theoretical disadvantage of crossing the gastroesophageal junction and are not optimal for long-term use. Some physicians have stated a preference for postpyloric feeding, citing lower rates of aspiration pneumonia and better tolerance of feeds. These tubes frequently require fluoroscopy for placement and are also subject to dislodgment. Rehabilitation centers are often reluctant to use nasojejunal tubes long term. Three recent studies using either nasoenteric feeding tubes or PEG feeding tubes have demonstrated no significant difference in aspiration or complication rates in gastric versus postpyloric feeding in non-TBI patients.16 –18 It has been hypothesized that either the pylorus, or both the pylorus and the lower esophageal sphincter, are rendered incompetent by the passage of these tubes.23 A recent paper by Saxe et al13 demonstrated incompetence of the lower esophageal sphincter following severe TBI and concluded that gastric feeding tubes were not safe for brain-injured patients. A subsequent study by Fox et al23 failed to show a correlation between the aforementioned lower esophageal dysfunction and aspiration in patients undergoing longterm gastric or jejunal feedings. This meta-analysis evaluated 45 studies with a total of 2,976 gastric tubes and 386
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jejunal tubes. Of these feeding tubes, 58% of the gastric tubes were placed endoscopically, and 66% of the jejunal tubes were transgastric. They found that aspiration rates were highly variable across different patient populations and studies, concluding that there is no evidence to support the preferential use of jejunal or gastric feeding tubes.24 It was our premise that despite concerns of decreased lower esophageal sphincter pressure and poor gastric emptying, gastric feeding could be safe and efficacious in patients with TBI. Our study did not demonstrate any increase in aspiration of gastric contents as a result of the esophageal sphincter dysfunction. Strict attention to patient positioning, as well as vigilant nursing care, helps to minimize the rates of complications with enteral access. These factors may actually be more important than the location of enteral access. Many institutions utilize nasojejunal feeding tubes as initial enteral access. Unfortunately, though, some physicians are not able to place a nasoenteric feeding tube that reaches the small intestine or remains in place in the TBI patient.10 Most patients with TBI do not require celiotomy. Thus, surgical placement of jejunal tubes would require a general anesthetic that is otherwise unnecessary. Additionally, the use of the long nasoenteric feeding tubes has been fraught with difficulty. Fluoroscopic placement requires transportation of a critically ill patient from the ICU for significant periods of time. There are potential hazards associated with transporting these patients to the radiology suite. The patient may not be properly ventilated, and sophisticated monitoring, especially intracranial pressure monitoring, may not be optimal. Additionally, these tubes may frequently not remain in the jejunum. With the pitfalls of these methods, we reviewed the safety and efficacy of PEG as enteral access in TBI patients. We routinely utilize PEG for enteral access in TBI patients and have found this to be a safe and easy procedure that frequently can be performed concomitantly with tracheostomy.14,25,26 Early PEG also establishes long-term access to expedite disposition.21 There are, however, inherent limitations to a retrospective chart analysis such as ours. Another concern is the possibility of ongoing subclinical aspiration of feedings in these patients. Pulmonary complications specifically related to enteral feedings would be very difficult to detect because of the high pneumonia rate among TBI patients. We found the pneumonia rate among our TBI patients to be 57%, which is less than the control group in a previous study on TBI patients.21 However, our prior experience suggests postpyloric feeding is of no advantage. Some of our success with gastric feeding may be related to the use of prokinetic agents to augment gastric emptying. We frequently utilize prokinetic agents such as metaclopramide in the initial 48 hours of enteral nutrition. Continuing use of these agents depends on the patient’s response to their discontinuance. Others have noted that gastric feeding in neurologically injured patients may be successful as early as 24 hours after the injury, with the coadministration of drugs to facilitate gastric emptying.27 Gastric feeding is clearly safe as well as effective following TBI, with no evidence of increased untoward events. In the 170
modern day of cost containment, the pertinent issue is whether there is a more efficient method of patient care. At our institution, a PEG tube costs $500 to $650, depending on the kit utilized. An open jejunostomy tube ranges from $2,800 to $3,900, whereas a fluoroscopic nasojejunal tube averages $1,400. When factors such as patient cost and overall convenience are considered, PEG as the initial enteral access seems intuitive.
REFERENCES 1. Grahm TW, Zadrozny DB, Harrington T. The benefits of early jejunal hyperalimentation in the head-injured patient. Neurosurgery. 1989;25:729 –735. 2. Borzotta AP, Osborne A, Bledsoe F, et al. Enteral nutritional support enhances cognitive recovery after severe closed head injury. Surg Forum. 1993;42:29 –34. 3. 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. 4. Moore FA, Moore EE, Jones TN, et al. TEN versus TPN following major abdominal trauma-reduced septic morbidity. J Trauma. 1989;29:916 –922. 5. 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. 6. Alverdy J, Chi HS, Sheldon GF. The effect of parenteral nutrition on gastointestinal immunity: the importance of enteral stimulation. Ann Surg. 1985;202:681– 684. 7. Gianotti L, Braga M, Vignali A, et al. Effect of route of delivery and formulation of postoperative nutritional support in patients undergoing major operations for malignant neoplasms. Arch Surg. 1997;132:1222–1229. 8. Daly JM, Weintraub FN, Shou J, et al. Enteral nutrition during multimodality therapy in upper gastrointestinal cancer patients. Ann Surg. 1995;221:327–338. 9. McClave SA, Greene LM, Snider HL, et al. Comparison of the safety of early enteral vs parenteral nutrition in mild acute pancreatitis. JPEN 1997;21:14 –20. 10. 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. 11. Norton JA, Ott LG, McClain C, et al. Intolerance to enteral feeding in the brain-injured patient. J Neurosurg. 1988;68:62– 66. 12. Weekes E, Elia M. Observations on the patterns of 24-hour energy expenditure changes in body composition and gastric emptying in head-injured patients receiving nasogastric tube feeding. JPEN. 1996;20:31–37. 13. Saxe JM, Ledgerwood AM, Lucas C, Lucas WF. Lower esophageal sphincter dysfunction precludes safe gastric feeding after head injury. J Trauma. 1994;37:581–586. 14. Carrillo EH, Heniford BT, Osborne DL, et al. Bedside percutaneous endoscopic gastrostomy. Surg Endosc. 1997;11:1068 –1071. 15. Spain DA, DeWeese RC, Reynolds MA, Richardson JD. Transpyloric passage of feeding tubes in patients with head injuries does not decrease complications. J Trauma. 1995;39:1100 –1102. 16. Marion M, Rappaport WD, Cunningham D, et al. The failure of conventional methods to promote spontaneous transpyloric feeding tube passage and the safety of intragastric feeding in the critically ill ventilated patient. Surg Gynecol Obstet. 1993;176:475– 479. 17. Strong RM, Condon SC, Solinger MR, et al. Equal aspiration rates from postpylorus and intragastric-placed small-bore nasoenteric feeding tubes: a randomized prospective study. JPEN. 1992; 16:59 – 63. 18. Kadakia SC, Sullivan HO, Starnes E. Percutaneous endoscopic
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gastrostomy and jejunostomy and the incidence of aspiration in 79 patients. Am J Surg. 1992; 164:114 –118. 19. Heyland DK, Konopad E, Alberda C, et al. How well do critically ill patients tolerate early, intragastric enteral feeding? Results of a prospective, multicenter trial. Nutrit Clin Pract. 1999; 14:23–28. 20. Chendrasekhar A. Jejunal feeding in the absence of reflux increases nasogastric output in critically ill trauma patients. Am Surg. 1996;62:887– 888. 21. Spain DA, McIlvoy LH, Fix SE, et al. Effect of a clinical pathway for severe traumatic brain injury on resource utilization. J Trauma. 1998;45:101–105. 22. McClave SA, Snider HL, Lowen CC, et al. Use of residual volume as a marker for enteral feeding intolerance: prospective blinded comparison with physical examination and radiographic findings. JPEN. 1992;16:99 –105.
23. Fox KA, Mularski BS, Sarfati MR, et al. Aspiration pneumonia following surgically placed feeding tubes. Am J Surg. 1995;170:564 – 567. 24. Lazarus BA, Murthy JB, Culpepper L. Aspiration associated with long-term gastric versus jejunal feeding: a critical analysis of the literature. Arch Phys Med Rehabil. 1990;71:46 –53. 25. Moore FA, Haenel JB, Moore EE, Read RA. Percutaneous tracheostomy and gastrostomy in brain injured patients. A minimally invasive alternative. J Trauma. 1992;33:435– 439. 26. D’Amelio LF, Hammond JS, Spain DA, Sutyak JP. Tracheostomy and percutaneous endoscopic gastrostomy in the management of the head-injured trauma patient. Am Surg. 1994;60: 180 –185. 27. Twyman, D. Nutritional management of the critically ill neurologic patient. Crit Care Clin. 1997;13:39-49.
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Routine Intragastric Feeding Following Traumatic Brain Injury Is Safe and Well Tolerated Charles T. Klodell, MD, Michelle Carroll, RN, BSN, Eddy H. Carrillo, MD, David A. Spain, MD, Louisville, Kentucky
BACKGROUND: Delayed gastric emptying following traumatic brain injury (TBI) has led some to advocate jejunal feeding. Our purpose was to review our experience with percutaneous endoscopic gastrostomy (PEG) and intragastric feeding in TBI patients to assess safety and effectiveness. METHODS: All patients on a TBI clinical pathway at our institution were targeted for early PEG. After PEG, standard enteral nutrition was initiated. Abdominal examination and gastric residual volumes were used to assess tolerance. RESULTS: There were 118 patients with moderate to severe TBI. The average age was 36 years. Mean Injury Severity Score (ISS) was 25. Enteral access was obtained and intragastric feeding was initiated on day 3.6. Intragastric feeding was tolerated without complication in 111 of 114 (97%) patients. Five patients aspirated, but had no evidence of intolerance prior to the event. CONCLUSIONS: PEG provided reliable enteral access in moderate to severe TBI patients. Intragastric feeding was well tolerated with a low complication rate (4%). Am J Surg. 2000;179: 168 –171. © 2000 by Excerpta Medica, Inc.
T
raumatic brain injury (TBI) continues to be a leading cause of morbidity and mortality in trauma patients. Early and adequate nutrition plays a crucial role in improving outcome.1–3 In a variety of patient populations, the enteral route for this early nutritional support has yielded superior results.2,4 –9 Even though the necessity of enteral access is widely accepted, the best method remains controversial. There have been reports of
From the Department of Surgery, University of Louisville School of Medicine (CTK, EHC, DAS), the Trauma Program in Surgery (EHC, DAS), University of Louisville Hospital (MC), and the Veterans Affairs Medical Center (DAS), Louisville, Kentucky. Presented as a poster at the 28th Educational and Scientific Symposium of the Society of Critical Care Medicine, San Francisco, California, January 24 –26, 1999. Requests for reprints should be addressed to David A. Spain, MD, Department of Surgery, University of Louisville, Louisville, Kentucky 40292. Manuscript submitted November 10, 1999, and accepted in revised form January 27, 2000.
168
© 2000 by Excerpta Medica, Inc. All rights reserved.
delayed gastric emptying following TBI and subsequent concern over the use of gastric feeding.10 –12 Saxe et al13 documented decreased pressure of the lower esophageal sphincter in an array of patients with neurological injuries. Many are opposed to gastric feeding in TBI because of these claims of decreased lower esophageal sphincter tone and poor gastric emptying. We attempt to demonstrate the safety and efficacy of gastric feeding in TBI patients. For these reasons, the placement of a jejunostomy tube has been touted superior to a gastrostomy tube, with claims of lower rates of pulmonary aspiration and better tolerance of feedings.1,13 Yet, others claim that smaller, softer, and longer nasoenteric feeding tubes that can be advanced into the proximal jejunum are preferred. Unfortunately, frequent dislodgment, obstruction of the lumen, and the cumbersome and time-consuming maneuvers to correctly place these tubes may limit their clinical usefulness.14 Some physicians favor the placement of transpyloric feeding tubes, citing lower complication rates. Spain et al15 noted that transpyloric passage had no effect on the time required to achieve full feeding, number of days on a ventilator, length of stay in the intensive care unit (ICU), pneumonia, aspiration, or mortality. Multiple studies in non-TBI patients have documented comparable rates of aspiration as well as complications associated with gastric and jejunal feeding tubes.15–19 Additionally, it has been shown that jejunal feeding tubes increased gastric output even in the absence of reflux.20 Gastrostomy tubes may also have an advantage because they do not cross the gastroesophageal junction, thus stenting it open. With these factors in mind, reevaluation of the method of enteral access in TBI patients is warranted. Bedside percutaneous endoscopic gastrostomy (PEG) is a safe and effective method of providing access to the gastrointestinal tract for nutritional support. In patients with significant TBI, this procedure can be safely performed in the ICU without secondary insult to the brain or untoward complications.14 At our institution, we have developed a clinical pathway for the management of TBI patients. This pathway utilizes a multidisciplinary approach for the total care of TBI patients and sets target dates for tracheostomy and PEG tube placement by postinjury day 4. This pathway has been prospectively studied and shown to expedite the disposition and rehabilitation of TBI patients without a negative impact on their overall care or recovery.21 Therefore, we undertook this study in an effort to delineate whether routine use of intragastric enteral nutrition is safe and effective in patients with TBI. 0002-9610/00/$–see front matter PII S0002-9610(00)00297-X
ROUTINE INTRAGASTRIC FEEDING AFTER TRAUMATIC BRAIN INJURY/KLODELL ET AL
TABLE Demographic Information Total patients Gender (men/women) Mean age (range) Mean ISS on admission (range) Mean NGT output (range)*
118 80/38 36 (15 to 83) 25 (9 to 43) 400 mL (0 to 1850 mL)
* Output was measured in the 24 hours before enteral feeding. ISS ⫽ Injury Severity Score; NGT ⫽ nasogastric tube.
PATIENTS AND METHODS We retrospectively reviewed the medical records of 118 moderate (Glasgow Coma Score [GCS] 8 to 12) to severe (GCS ⬍ 8) TBI patients admitted to our academic level I trauma center over a 3-year period (1996 to 1999) and who were placed on TBI pathways. The records were reviewed for demographic data, injury severity, and nasogastric tube outputs before enteral access as well as tolerance of enteral nutrition. All patients were in an ICU at initiation of feeding, and tolerance of tube feeds was evaluated every 4 hours based on gastric residuals as well as an abdominal examination.22 As part of the protocol for enteral feeding, all patients were fed in a 30-degree upright position, and feedings were administered as a continuous drip by a mechanical pump. Predictive equations were utilized to calculate basal energy expenditure and caloric goals. Substrate targets were set at 55% to 60% carbohydrate, 20% protein, and 20% to 25% fat. Our standard formula has this allocation of substrate, as well as added fiber. Typically, the initial rate was 25 mL per hour and was subsequently increased by 25 mL per hour every 8 to 12 hours, until the goal rate was reached. Tracheal secretions were routinely checked for tube feed dye. Gastric residual volume was checked every 8 hours, and tube feedings were stopped when gastric residual volume exceeded 200 mL. Tube feedings were then reinitiated at the previous rate when gastric volume lowered to less than 200 mL at the next measurement. Food coloring was added to all feedings, and aspiration was defined as retrieval of colored aspirate from the tracheobronchial tract, whether or not consequences were noted on chest roentgenograms. In nearly 50% of cases, prokinetics were initiated concurrently with enteral nutrition. Metacloperamide was used most commonly, although cisapride was chosen occasionally. In most cases, these agents were withdrawn after 48 hours, and their ongoing use was contingent on the response to discontinuance.
RESULTS There were 80 men and 38 women whose average age was 36 years (range 15 to 83). The mean ISS was 25 (range 9 to 43; Table). There were 89 patients with severe TBI (GCS⬍8) and 29 patients with moderate TBI (GCS ⫽ 8 to 12). On average, enteral access was obtained and gastric feeding instituted within 3.6 days of hospital admission. Thirteen patients received enteral nutrition on postinjury day 1. More than 80% of the patients received a PEG tube for initial enteral access, and the remainder received a small-bore nasogastric tube. The Dobhoff tube was used only in patients with extremely elevated intracranial pres-
sures. Traumatic brain injuries did not delay initiation of enteral nutrition. Ultimately, PEG tubes were placed in 97% (114 of 118) of patients. No complications related to the gastrostomy tube placement occurred. Four patients recovered rapidly from their TBI and were able to have the nasogastric feeding tube removed. The mean nasogastric tube output in the 24 hours before enteral feeding was 400 mL. Overall, 111 of 114 (97%) TBI patients were able to tolerate intragastric nutrition. Two patients required endoscopic conversion to combination gastrostomy-jejunostomy tubes, related to gastroparesis and high gastric residuals. No single factor was predictive of the patients who required conversion to jejunal tubes, and both patients subsequently tolerated jejunal feedings. A third patient was taken to the operating room for unrelated reasons, and a jejunostomy tube was placed during laparotomy. No patient required conversion to parenteral nutrition. Of the 97% of patients who tolerated gastric nutrition, 77% (85 of 111) of the patients were at the goal rate by the fourth day of nutritional support. Many patients (37 of 111) were able to reach the goal rate within 48 hours. Five patients (4%) were noted to have aspiration related to initiation of enteral nutrition and subsequently developed pneumonia; 4 of these patients had PEG tubes at the time of the aspiration event. Neither nasogastric outputs nor gastric residuals were predictive of which patients would aspirate, with average gastric residuals of ⬍100 mL in this subset. All 5 patients tolerated subsequent gastric feeding without further incidents.
COMMENTS The benefits of early nutritional support in TBI patients are well known. The preference for enteral nutrition, as opposed to parenteral, is also nearly universal. However, controversy still remains regarding the route of administration. Some physicians advocate the use of nasogastric feeding tubes. These tubes are easily placed and are relatively inexpensive, but they suffer from frequent dislodgment that interrupts nutrition. They also pose the theoretical disadvantage of crossing the gastroesophageal junction and are not optimal for long-term use. Some physicians have stated a preference for postpyloric feeding, citing lower rates of aspiration pneumonia and better tolerance of feeds. These tubes frequently require fluoroscopy for placement and are also subject to dislodgment. Rehabilitation centers are often reluctant to use nasojejunal tubes long term. Three recent studies using either nasoenteric feeding tubes or PEG feeding tubes have demonstrated no significant difference in aspiration or complication rates in gastric versus postpyloric feeding in non-TBI patients.16 –18 It has been hypothesized that either the pylorus, or both the pylorus and the lower esophageal sphincter, are rendered incompetent by the passage of these tubes.23 A recent paper by Saxe et al13 demonstrated incompetence of the lower esophageal sphincter following severe TBI and concluded that gastric feeding tubes were not safe for brain-injured patients. A subsequent study by Fox et al23 failed to show a correlation between the aforementioned lower esophageal dysfunction and aspiration in patients undergoing longterm gastric or jejunal feedings. This meta-analysis evaluated 45 studies with a total of 2,976 gastric tubes and 386
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ROUTINE INTRAGASTRIC FEEDING AFTER TRAUMATIC BRAIN INJURY/KLODELL ET AL
jejunal tubes. Of these feeding tubes, 58% of the gastric tubes were placed endoscopically, and 66% of the jejunal tubes were transgastric. They found that aspiration rates were highly variable across different patient populations and studies, concluding that there is no evidence to support the preferential use of jejunal or gastric feeding tubes.24 It was our premise that despite concerns of decreased lower esophageal sphincter pressure and poor gastric emptying, gastric feeding could be safe and efficacious in patients with TBI. Our study did not demonstrate any increase in aspiration of gastric contents as a result of the esophageal sphincter dysfunction. Strict attention to patient positioning, as well as vigilant nursing care, helps to minimize the rates of complications with enteral access. These factors may actually be more important than the location of enteral access. Many institutions utilize nasojejunal feeding tubes as initial enteral access. Unfortunately, though, some physicians are not able to place a nasoenteric feeding tube that reaches the small intestine or remains in place in the TBI patient.10 Most patients with TBI do not require celiotomy. Thus, surgical placement of jejunal tubes would require a general anesthetic that is otherwise unnecessary. Additionally, the use of the long nasoenteric feeding tubes has been fraught with difficulty. Fluoroscopic placement requires transportation of a critically ill patient from the ICU for significant periods of time. There are potential hazards associated with transporting these patients to the radiology suite. The patient may not be properly ventilated, and sophisticated monitoring, especially intracranial pressure monitoring, may not be optimal. Additionally, these tubes may frequently not remain in the jejunum. With the pitfalls of these methods, we reviewed the safety and efficacy of PEG as enteral access in TBI patients. We routinely utilize PEG for enteral access in TBI patients and have found this to be a safe and easy procedure that frequently can be performed concomitantly with tracheostomy.14,25,26 Early PEG also establishes long-term access to expedite disposition.21 There are, however, inherent limitations to a retrospective chart analysis such as ours. Another concern is the possibility of ongoing subclinical aspiration of feedings in these patients. Pulmonary complications specifically related to enteral feedings would be very difficult to detect because of the high pneumonia rate among TBI patients. We found the pneumonia rate among our TBI patients to be 57%, which is less than the control group in a previous study on TBI patients.21 However, our prior experience suggests postpyloric feeding is of no advantage. Some of our success with gastric feeding may be related to the use of prokinetic agents to augment gastric emptying. We frequently utilize prokinetic agents such as metaclopramide in the initial 48 hours of enteral nutrition. Continuing use of these agents depends on the patient’s response to their discontinuance. Others have noted that gastric feeding in neurologically injured patients may be successful as early as 24 hours after the injury, with the coadministration of drugs to facilitate gastric emptying.27 Gastric feeding is clearly safe as well as effective following TBI, with no evidence of increased untoward events. In the 170
modern day of cost containment, the pertinent issue is whether there is a more efficient method of patient care. At our institution, a PEG tube costs $500 to $650, depending on the kit utilized. An open jejunostomy tube ranges from $2,800 to $3,900, whereas a fluoroscopic nasojejunal tube averages $1,400. When factors such as patient cost and overall convenience are considered, PEG as the initial enteral access seems intuitive.
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gastrostomy and jejunostomy and the incidence of aspiration in 79 patients. Am J Surg. 1992; 164:114 –118. 19. Heyland DK, Konopad E, Alberda C, et al. How well do critically ill patients tolerate early, intragastric enteral feeding? Results of a prospective, multicenter trial. Nutrit Clin Pract. 1999; 14:23–28. 20. Chendrasekhar A. Jejunal feeding in the absence of reflux increases nasogastric output in critically ill trauma patients. Am Surg. 1996;62:887– 888. 21. Spain DA, McIlvoy LH, Fix SE, et al. Effect of a clinical pathway for severe traumatic brain injury on resource utilization. J Trauma. 1998;45:101–105. 22. McClave SA, Snider HL, Lowen CC, et al. Use of residual volume as a marker for enteral feeding intolerance: prospective blinded comparison with physical examination and radiographic findings. JPEN. 1992;16:99 –105.
23. Fox KA, Mularski BS, Sarfati MR, et al. Aspiration pneumonia following surgically placed feeding tubes. Am J Surg. 1995;170:564 – 567. 24. Lazarus BA, Murthy JB, Culpepper L. Aspiration associated with long-term gastric versus jejunal feeding: a critical analysis of the literature. Arch Phys Med Rehabil. 1990;71:46 –53. 25. Moore FA, Haenel JB, Moore EE, Read RA. Percutaneous tracheostomy and gastrostomy in brain injured patients. A minimally invasive alternative. J Trauma. 1992;33:435– 439. 26. D’Amelio LF, Hammond JS, Spain DA, Sutyak JP. Tracheostomy and percutaneous endoscopic gastrostomy in the management of the head-injured trauma patient. Am Surg. 1994;60: 180 –185. 27. Twyman, D. Nutritional management of the critically ill neurologic patient. Crit Care Clin. 1997;13:39-49.
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