The nutritional management of patients with head injuries

Severe head injuries tend to be associated with hypermetabolism and hyperca tabolism resulting in negative nitrogen balances which may exceed 30 grams day(-1). Enteral feeding should begin as soon as the patient is hemodynamic ally stable, attempting to reach a non-protein caloric intake of at least 3 0-35 kcal kg(-1) day(-1) and a protein intake of 2.0-2.5 g kg(-1) day(-1) a s soon as possible. With severe head injuries (Glasgow Coma Scale < 8), the re is an increased tendency for gastric feeding to regurgitate into the upp er airway Keeping the patient upright and checking residuals is import-ant in such patients. Jejunal feedings are less apt to be aspirated. if it is a pparent that the gastro-intestinal tract cannot be used to reach the nutrit ional goals within three days, total parental nutrition is begun within 24- 48 h so as to reach these nutrition goals by either one or both routes by t he third or fourth day. Blood glucose levels exceeding 150-200 mg dl(-1) te nd to increase the severity of the neurologic problems and efforts should b e made to prevent hyperglycemia by carefully regulating the glucose and ins ulin intake. Indirect calormetry to determine the respiratory quotient and resting energy expenditure should be determined twice weekly. To determine N-2 balance, urinary urea nitrogen should be measured in 24-h specimens. Th ese tests should be performed once or twice weekly until it is clear that t he nutrition is adequate.