Enteral Nutrition in Neurological Patients

Abstract

Nutrition support therapy is part of the basic care of the neurological patient in the intensive care unit (ICU). The presence of malnutrition has been identified as an independent factor for poor prognosis. Enteral nutrition (EN) is the preferred way of feeding the critically ill patient and an important mean of counteracting for the catabolic state induced by disease, when patients are not expected to be on a full oral diet within 3 days since admission. During the initial acute phase of a critical disease, a caloric provision of 20–25 kcal/kg BW/day is the most favorable. During the anabolic recovery phase, the goal should be set at 25–30 kcal/kg/day. Recommended protein intake is 1.2–2.0 g/kg BW/day. Whole protein commercial formulations are appropriate for most patients, and they are designated to provide the required amount of vitamins and trace elements with an intake of 1,500–2,000 kcal. Both gastric and postpyloric feedings are appropriate for critically ill patients, but nasogastric tubes are the first choice. Administration through a continuous infusion pump is better tolerated than bolus administration, and it allows achieving nutritional goals much more frequently.

EN intolerance (abdominal distension, diarrhea, or regurgitation with risk of bronchoaspiration) is a bad prognostic indicator in the critically ill patient and leads to a decrease in nutrient intake and a compromised nutritional status. Therefore, it should be carefully evaluated and treated. Paralytic ileus refractory to prokinetic drugs and to postpyloric enteral nutrition can develop in severely ill patients in coma, so total or supplementary parenteral nutrition should be considered in these patients.

After a traumatic brain injury (TBI), patients enter a hypercatabolic state that can originate complications as malnutrition, hyperglycemia, muscle wasting, impaired wound healing, increased risk for infections, and multiple organ failure, even when the patient was previously well nourished.

Stroke patients are often malnourished, since they are usually older and have frequent comorbidities that can change their nutritional requirements. Dysphagia has a great influence on the patient’s prognosis during his/her stay in the ICU. Half of the patients with stroke and dysphagia develop bronchoaspiration episodes, and they have a higher incidence of aspiration pneumonia. Swallowing dysfunction should therefore be early and carefully evaluated in patients with stroke but also in patients with Guillain-Barré syndrome, myasthenia gravis, or systemic sclerosis.

Ten to twenty percent of body weight is lost during the first 4 weeks after a traumatic spinal cord injury, of which around 85 % is lean mass. Nitrogen balance turns positive not before 7–8 weeks after the injury. In this context, a provision of 20–22 kcal/kg BW for tetraplegic patients and 23–24 kcal/kg BW for paraplegic patients is recommended.

Therefore, nutritional status worsens after a neurological injury in virtually all patients, so that nutritional support interventions should be undertaken as part of these patients’ routine care in all clinical settings.