Nutritional support for head-injured patients

  • Review
  • Intervention

Authors


Abstract

Background

Head injury increases the body's metabolic responses, and therefore nutritional demands. Provision of an adequate supply of nutrients is associated with improved outcome. The best route for administering nutrition (parenterally (TPN) or enterally (EN)), and the best timing of administration (for example, early versus late) of nutrients needs to be established.

Objectives

To quantify the effect on mortality and morbidity of alternative strategies of providing nutritional support following head injury.

Search methods

Trials were identified by computerised searches of the Cochrane Injuries Group specialised register, Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, National Research Register, Web of Science and other electronic trials registers. Reference lists of trials and review articles were checked. The searches were last updated in July 2006.

Selection criteria

Randomised controlled trials of timing or route of nutritional support following acute traumatic brain injury.

Data collection and analysis

Two authors independently abstracted data and assessed trial quality. Information was collected on death, disability, and incidence of infection. If trial quality was unclear, or if there were missing outcome data, trialists were contacted in an attempt to get further information.

Main results

A total of 11 trials were included. Seven trials addressed the timing of support (early versus delayed), data on mortality were obtained for all seven trials (284 participants). The relative risk (RR) for death with early nutritional support was 0.67 (95% CI 0.41 to 1.07). Data on disability were available for three trials. The RR for death or disability at the end of follow-up was 0.75 (95% CI 0.50 to 1.11). Seven trials compared parenteral versus enteral nutrition. Because early support often involves parenteral nutrition, three of the trials are also included in the previous analyses. Five trials (207 participants) reported mortality. The RR for mortality at the end of follow-up period was 0.66 (0.41 to 1.07). Two trials provided data on death and disability. The RR was 0.69 (95% Cl 0.40 to 1.19). One trial compared gastric versus jejunal enteral nutrition, there were no deaths and the RR was not estimable.

Authors' conclusions

This review suggests that early feeding may be associated with a trend towards better outcomes in terms of survival and disability. Further trials are required. These trials should report not only nutritional outcomes but also the effect on death and disability.

摘要

背景

頭部損傷病人的營養維持

頭部損傷增加身體的代謝反應,因此增加營養需求。適當的提供營養支持與改善結果有關。提供營養的最佳管道(腸胃外的(TPN)或腸內的(EN)),及最佳的營養提供時間(例如,早期對於晚期)都需要建立。

目標

將死亡率和罹病率加以量化,以評估頭部損傷後選擇提供營養支援的策略。

搜尋策略

經由電腦化的搜尋登錄於Cochrane損傷專門性群組、登錄Cochrane中心的控制性的試驗、EMBASE、登錄在National Research、登錄在科學和其他電子的試驗網站。也查閱試驗及評論文章的文獻目錄。搜尋最後一次更新為2006年7月。

選擇標準

急性腦損傷後營養維持的時間與管道的隨機對照試驗。

資料收集與分析

兩位作者獨立的摘取資料及評估試驗品質。收集死亡、失能、及感染發生率的訊息。如果試驗品質不清楚,或若有遺失結果資料,將接觸試驗者以企圖獲得進一步的訊息。

主要結論

合計納入11篇試驗。7篇試驗探討支持的時間(早期對晚期),7篇試驗均獲得死亡率的資料(284位參與者)。早期營養支持的死亡相對危險比(RR)是0.67(95% CI 0.41 to 1.07)。三篇試驗有可利用之失能資料。追蹤結束之死亡或失能的相對危險比是0.75 (95% CI 0.50 to 1.11)。7篇試驗比較非腸道對於腸道營養。因為早期支持常常包括非腸道的營養,這些試驗中的3篇也包括之前的分析。5篇試驗(207位參與者)有報告死亡率。追蹤結束之死亡率的相對危險比是0.66 (0.41 to 1.07)。2篇試驗提供死亡及失能的資料。相對危險比是0.69 (95% Cl 0.40 to 1.19)。1篇試驗比較胃相對於空腸的營養支援,但沒有死亡資料且沒有估計相對危險比。

作者結論

此篇評論建議早期供給營養可能有較好的預後並改善失能。未來需要更進一步的試驗。這些試驗應報告不僅是營養的結果,也應有死亡及失能的影響。

翻譯人

本摘要由高雄榮民總醫院林麗英翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

營養支持投予的時間與路徑,對頭部損傷病人的存活及失能有影響嗎?在中度到重度的頭部損傷後,當他們的身體的新陳代謝正在以更快的速率工作時,病人使用更多的能量。這增加身體的營養需要,可能導致營養不良及其他的合併症。即使可以口進食,病人經常不能單獨以口進食來滿足增加的需求,因此需要其他的方法。無論如何,營養支持的方法和時間可以不同。有些可以在頭部損傷後立即開始,但是其他的可能延遲到消化系統有功能才開始。腸道營養經由鼻子或嘴巴插入灌食管子來供給,進入胃或小腸內。全靜脈營養(Total parenteral nutrition, TPN)意指病人僅由靜脈內供給營養。此方法可能帶來感染合併症的危險。提供營養的時間及管道是否對頭部損傷病人的死亡率及罹病率有影響是不清楚的。此系統性評論的作者們搜尋所有高品質試驗,以追蹤確認頭部損傷後,最佳的時間(早期或晚期),及營養提供的管道(腸道或非腸道)。作者發現11篇合格的試驗,調查頭部損傷病人營養支持的時間與管道。這些試驗總共包括534位病人。無論如何,多數試驗有方法學上的缺點。作者們發現早期提供營養可能與較少的感染及較好的存活和改善失能有關。無論如何,此試驗是小型的,因此發現的任何改善幅度也小。也因為很多試驗的焦點是在營養的結果,並沒報告死亡和失能的影響。作者們從所有納入的試驗中無法獲得死亡和失能的資料,因此認為有偏差的可能性。在頭部損傷後更進一步的營養支援的試驗是需要的。這些試驗應該像報告營養結果一樣的報告死亡及失能。他們也應該大到足夠察覺臨床重要的處理效果。

Plain language summary

Does the timing and route of nutritional support have an effect on survival and disability in head-injured patients?

After a moderate or severe head injury, patients use more energy as their body's metabolism is working at a greater rate. This increases the body's nutritional requirements which may lead to malnutrition and other complications.

Patients are often unable to meet the increased requirements by oral feeding alone, even if oral feeding is possible, therefore other methods are required. However, the method and timing of nutritional support can differ. Some can be started immediately following head injury but others may be delayed until the digestive system is found to be functioning.

Enteral nutrition is provided by inserting a feeding tube via the nose or mouth, into the stomach or small intestine. The feeding tube delivers a liquid formula containing the required nutrients. Total parenteral nutrition (TPN) provides an alternative to conventional enteral feeding. Parenteral nutrition means feeding someone via their blood stream (intravenously). Total parenteral nutrition (TPN) means that a patient is only fed intravenously. This method may carry risks of infectious complications.

It is unclear whether the timing and route of the administration of nutrition has an effect on mortality and morbidity of head-injured patients. The authors of this a systematic review searched for all high quality trials to determine the best timing (early or delayed), and route (enteral or parental) of nutritional support following head injury.

The authors identified 11 eligible trials that investigated the timing and route of nutritional support in head-injured patients. These trials included a total of 534 patients. However, of the many of the trials had methodological weaknesses.

The authors found that early feeding may be associated with fewer infections and a trend towards better outcomes in terms of survival and disability. However, the trials were small so any improvements detected were on a small scale. Also the focus of many of the trials was on nutritional outcomes, and many did not report the effect on death and disability. The authors were unable to obtain data for death and disability for all of the included trials so they feel there may be a possibility of bias. Further trials of nutritional support following head injury are required. These trials should report death and disability as well nutritional outcomes. They should also be large enough to detect clinically important treatment effects.

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