Early Enteral Nutrition After Brain Injury by Percutaneous Endoscopic Gastrojejunostomy DONALD F. KIRBY, M.D., F.A.C.P., F.A.C.N., GUY L. CLIFTON, M.D., HOPE TURNER, M.S., R.N., DONALD W. MARION, M.D., JUDY BARRETT, R.N., AND HANNS-DIETER F. GRUEMER, M.D. From the Nutrition
the Divisions of Gastroenterology and Neurosurgery, and the Department of Pathology, Commonwealth University, Medical College of Virginia Hospitals, Richmond, Virginia
Support Seruice,
Virginia
ABSTRACT. Twenty-seven patients in a series of 52 patients with severe brain injury (Glasgow Coma Scale score ≤8) underwent insertion of intestinal feeding tubes at the bedside. The technique required endoscopy with externalization of gastric and intestinal ports through the abdominal wall. Feedings were begun through the intestinal tube with Vital HN within 4 hours of its insertion with simultaneous gastric decompression via the gastric tube. Tubes were placed 2.3 (range 0-5) days after injury. Full caloric intake (3020 kcal/24 h) was achieved by 6.8 (range 2-8) days after injury to 4.2 (range 2-8) days after placement of the feeding tube. Only 1 patient failed to tolerate feedings immediately after tube insertion. Technical inability to insert the tubes occurred in 3 patients and the intestinal tube migrated into the stomach in 2 patients; diarrhea occurred in only 1 patient. With this technique, it was possible to deliver
an average daily intake of 1.2 g/kg of protein in 8-day balance periods beginning at the time of tube insertion. These data included 3- to 4-day periods in which feedings were steadily increased. In 16 patients in whom nitrogen balance was measured for 8-day balance periods, average nitrogen balance was -5.7 (range -11.3 to +3.5) g/24 h. The reduction in nitrogen loss by this technique appears equal to or superior to either gastric feeding or TPN. This technique provides the ability to enterally feed a high proportion of brain-injured patients (except those in barbiturate coma) very early after injury using a bedside procedure. It is concluded that intestinal feeding is the procedure of choice for the nutritional management of the Journal of Parenteral and Enteral Nubrain-injured patient. (
A number of different feeding methods have been tested to improve nutritional management of brain-injured patients, since description of the metabolic response to brain injury.1-4 The two goals of management have been early caloric and protein replacement and reduction of negative nitrogen balance. Achievement of full caloric replacement within 3-5 days by total parenteral nutrition (TPN) or jejunal feeding has been associated with more rapid neurologic recovery and with reduced infectious complications.3-5 Gastric enteral feeding in brain-injured patients has not been as satisfactory as TPN or jejunal feedings.3°4°6°’ In previous work we compared nitrogen balance achieved by enteral infusion of two large quantities of high protein content formulas in 20 patients. Considerable attention to details of feeding with individualized adjustment of feeding rates was required. In this study 20% of patients did not tolerate gastric enteral feedings due to diarrhea or delayed gastric emptying, and full caloric intake was achieved in the rest on the average 8 days after injury.1 Other investigators have shown radiographically in severely brain-injured patients a defect in gastric emptying lasting 2 weeks, found intolerance to enteral feeding at 10 days postinjury in 50% of patients, and reported aspiration pneumonitis in 22% of patients fed gastrically.6,7 The best efforts of Young et aP at gastric feeding
resulted in full caloric replacement at 12 days after injury and lower nitrogen balances than they achieved with TPN. For these reasons, most brain injury centers have simply used TPN for 2-3 weeks after injury and then converted to gastric feeding.
Reprint requests: Donald F. Kirby, MD, Box 711, MCV Station, Richmond, VA 23298-0711.
trition 15 :298-302, 1991)
Jejunal feedings have been increasingly used, rather than TPN, after gastric and duodenal surgery.8-10 Jejunal feeding in brain-injured patients by nasojejunal tubes has been reported to supply full caloric intake within 3 days of brain injury.3 We and others have found radiographic insertion of nasojejunal tubes to be difficult and migration of the tubes out of the jejunum and into the stomach to be frequent.6 To test another approach, 27 of a series of 52 patients with severe brain injury underwent endoscopic placement at the bedside of a percutaneous endoscopic gastrostomy (PEG) tube with a smaller feeding tube that has both gastric and intestinal ports (PEG/ J). The time to full caloric replacement was measured in these 27 patients. Nitrogen balance was measured in 16 patients to assess the outcome of intestinal feedings as compared to previously published data with parenteral and gastric feedings in brain-injured patients. MATERIALS AND METHODS
Population and Management Fifty-two patients with severe brain injury (Glasgow Coma Scale [GCS] scores8) on admission were admitted to Medical College of Virginia Hospitals from January through December 1989. Patients underwent early intu-
Patient
Downloaded from pen.sagepub.com at The University of Iowa Libraries on June 1, 2015
299
bation, and computerized tomographic
scans were
per-
formed within 1 hour of admission with immediate
cra-
niotomy for those with mass lesions. Intracranial pressure (ICP) monitors were placed in all patients. Patients were managed on rotational beds (Kinetic Concepts, Inc, San Antonio, TX). Intracranial pressure ~20 mm Hg 35 mm was treated first by hyperventilation (PaCo2 Hg) and ventricular drainage and, if not controlled by these measures, mannitol (0.25 g/kg) was administered. =
was used to maintain blood levels of 70to treat elevated ICP in four patients who had
Pentobarbital 90
mg/L
ICP uncontrollable by other means. Swan-Ganz catheters were placed and pulmonary capillary wedge pressure maintained a12 mm Hg by infusion of crystalloid when barbiturates or mannitol were used. Jejunal feeding tubes were placed in 30 patients. PEG/ J tubes were inserted in 27 patients, a nasojejunal tube in 1, and surgical placement of a PEG/J tube in 2. Of the remaining 22 patients, 7 were nutritionally managed with TPN, 6 with nasogastric feedings, and 9 patients with GCS of 3 and/or difficult-to-control increased ICP had no nutritional management. These latter 9 patients died within 7 days of injury.
Management of PEG/J Tubes Nasogastric or orogastric tubes were placed on admission in all patients and kept to intermittent suction. Only patients who had had a negative diagnostic paracentesis were eligible for placement of a PEG tube with small intestinal feeding tube (PEG/J). As soon as possible and always within 5 days of injury (mean 2.3, range 0-5 days), 27 patients underwent placement of PEG/J tubes. After routine endoscopic evaluation for exclusion of significant ulcer disease, a PEG catheter (size 18-28 French) was placed into the stomach. A PEG/J tube was then guided through the established PEG and the jejunal catheter pulled with a grasping forceps into the small intestine. An x-ray was obtained to verify the position of the small intestinal tube. Figure 1 illustrates the PEG/J tube. The following feeding tubes were used: 18 Fr SacksVine PEG with 10 Fr G/J Tube 14/26 (54%) (Ross Laboratories, Columbus, OH), 22 Fr Caluso PEG with 10 Fr G/J Tube 1/26 (4%) (Superior Biosystems Inc, Cumberland, RI), and 28 Fr Caluso PEG with 12 Fr G/ J 11/26 (42%). After placement, water was infused over the first 2-4 hours and if no significant intolerance occurred, then full-strength isotonic feedings were begun at 50 mL/h and increased by 25 mL/12 h until the desired rate was reached. Vital HN, which contains 10% fat, 74% carbohydrate, and 16% hydrolyzed protein, was fed by continuous infusion. Vital HN has 6.7 g of nitrogen per liter with a nonprotein calorie to nitrogen ratio of 125:1. Caloric requirements for each patient were estimated by previously published formulas. 11 Intermittent gastric suction via the gastric port of the PEG/J tube was carried out throughout the period of intestinal feedings. Feedings . were stopped only for abdominal distention with the absence of bowel sounds as determined by physical examination or recovery of tube feeding via the gastric port
FiG. 1. Example of a PEG/J tube with the gastrostomy tube anchored in the stomach and the intestinal J-tube placed into the small intestine. Note the two ports on this tube: one for gastric suction and one for intestinal feeding.
of the PEG/J (indicating that the tube had slipped out of place). Most patients had methylene blue added to their tube feeding to facilitate rapid identification of tube feeding refluxing into the stomach or suspicious gastric drainage was monitored for glucose indicating the presence of tube feeding in those patients whose tube feeding was not colored. Absent bowel sounds alone did not necessitate discontinuation of feedings, but feedings were not administered to patients in barbiturate coma. After an average of 2 weeks of intestinal feedings, the gastric port was used for nourishment. After it was established that gastric feedings were tolerated, the intestinal tube was removed from the PEG tube and a feeding adaptor placed on the tube to allow further feeding into the stomach. Nutritional Measurement
All urine was collected daily via a Foley catheter in containers with 30 mL of 1 mol/L hydrochloric acid. Urine was measured and mixed by research personnel and urinary nitrogen measured by the chemilumines-
technique (Antek Instruments, Houston, TX). 12 g/L of protein, the coefficient of variation of this technique was 4.34%. Balance periods of continuous urine collection were begun on the first to third day after injury and continued for 5-13 days. cence
At 6.9
RESULTS
The characteristics of the 52 patients in this study including GCS, primary diagnosis, and outcome are shown in Table I. Patients were eligible for PEG/J placement if they had no intraabdominal insult that precluded safe endoscopic placement of the PEG/J tube or contraindication such as neck instability or significant facial fractures that made oral intubation with an endoscope impossible. Patients not fed jejunally are divided into four groups: those managed by TPN, those managed
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300 TABLE I Patients’ characteristics
*
Primary diagnosis: DBI, diffuse brain injury; EDH, epidural hematoma; SDH, subdural hematoma; ICH, intracerebral hematoma. GR, good recovery; MD, moderate disability; SD, severe disability; V, vegetative; D, dead.
t Outcome:
by nasogastric feedings,
those without nutritional
agement, and those in whom PEG/J tubes
were
man-
placed
but not used acutely. In 9 patients, PEG/J tubes were inserted but, because of increased ICP requiring barbiturate coma, acute renal failure limiting fluid intake, or early death, they were not used for management. Except for patients with no nutritional management, who were the oldest and most severely injured, the remainder are similar in injury severity and outcome to patients who underwent jejunal feeding. Differences in outcome among groups appear to reflect differences in injury severity, not mode of nutritional management. Table II gives caloric data for each of 21 patients who underwent insertion of a jejunal feeding tube with nutritional management and gives nitrogen balance data for 16 randomly selected patients in this group. The timing of PEG/J tube insertion is shown. Also shown is the time after admission and time after PEG/J tube insertion by which full caloric intake based on calculated requirements was achieved. Maximal levels of caloric and nitrogen intake are also shown in Table II. PEG/J tubes were Caloric data
on
inserted
a mean of 2.3 (range 0-5) days from injury and 4.2 (range 2-8) days were required to reach full caloric intake. This resulted in full intake 6.8 (range 3-12) days after injury. The average time during which the nitrogen balance was measured continuously was 7.7 (range 5-12) days. The mean caloric intake for the balance period was 1867 kcal/24 h and ranged from 1060 kcal/24 h to 2640 kcal/24 h. At maximal caloric intake 2400-3360 kcal/24 h, with an average of 3020 kcal/24 h, was administered. Average protein intake for the balance period was 1.2 g/ kg per 24 hours. Mean nitrogen intake for this balance period was 12.5 (range 7.11-18.5) g/24 h. Assuming 2 g for fecal and cutaneous nitrogen loss, total nitrogen excretion was 17 (range 7-24) g/24 h, resulting in a nitrogen balance of -5.7 (range -11.3 to +3.5) g/24 h. Balance periods incorporate 4-day periods when intestinal alimentation was being steadily increased and,
caloric and nitrogen intakes represent days of low intake early in the balance period and higher intake later. PEG/J tube insertion required a skilled endoscopist.
therefore, an
mean
average of
TABLE II those patients fed via jejunal feeding tube
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301
After insertion, the majority of intestinal tubes were in the second portion of the duodenum by radiographic evaluation and the remainder in the jejunum. Either location resulted in satisfactory feeding tolerance. Difficulties with PEG/J tube placement were an inability to pass the second portion of the duodenum with the jejunal feeding tube in two patients and inability to pass an edematous pharynx in another. These patients were all treated with TPN. In seven cases, the internal bumper used to anchor the Sacks-Vine tubes against the stomach eroded the abdominal wall at 11-36 weeks after injury. This led to abandonment of use of the Sacks-Vine tube. Use of the Caluso PEG tube eliminated this complication. In two cases, the intestinal tube slipped back into the stomach and in one case gastroduodenal reflux resulted in the tube migrating into the duodenal bulb. In two cases, the tube became occluded due to Kayexalate or crushed medications. One was reopened and the other was endoscopically replaced. Absorption of feedings must have been total inasmuch as there was no stool at all for the first 2 weeks after PEG/J tube insertion except for one patient who developed diarrhea. Abdominal distention necessitated discontinuing feedings in only one patient. DISCUSSION
Our purpose was to establish whether intestinal feeding via a catheter percutaneously inserted at the bedside resulted in a high level of tolerance of feedings early after injury in patients with severe brain injury. We further wished to establish whether nitrogen balance with such an approach was at least equivalent to values previously established for gastric feeding and TPN. We did not attempt to establish improvement in outcome by this approach. We achieved full intake by the seventh day after injury with tube insertion on the second day. Importantly, we also observed intolerance of feedings in only 1 of 21 patients not in barbiturate coma. Like Grahm et al,3 we found with use of a small intestinal feeding tube that ability to deliver calories and to reduce nitrogen loss early after injury were equal or superior to data reported with gastric enteral feeding or TPN in brain-inured patients. Nitrogen balance by PEG/J tube was -5.7 g/24 h with 12.4 g/24 h nitrogen intake, comparing favorably with published data. Nitrogen balance data in our previous studies of gastric enterally fed braininjured patients showed nitrogen balances of -9.2 g/24 h with 17.6 g/24 h nitrogen intake in balance periods
beginning on day 8.1 Young et al5 reported negative nitrogen balance of -6 g/24 h in the first week after injury with 15 g/24 h nitrogen intake by TPN. Investigators have attempted to improve nutritional management of the brain-injured patient by three different routes of feeding: parenterally with TPN and enterally by gastric or small intestinal feeding. We previously used gastric enteral feeding, finding that 20% of patients would not tolerate enteral feeding until the second week after injury. In this study, large amounts of calories and nitrogen could be delivered by day 8 after injury in those patients who tolerated gastric enteral alimentation the first week.
in
Young and colleagueS5 were able to achieve full caloric intake at 12 days after injury by gastric enteral feedings with their best effort, but 35% of patients did not tolerate gastric feedings by day 7 after injury. The difficulties in consistently feeding patients early after brain injury by gastric enteral feeding have been elucidated by Ott et al,’ who showed radiographically that 7 of 12 brain-injured patients had delayed gastric emptying of liquids during the first postinjury week. TPN for the first 2 weeks after injury has been the most widely used feeding technique in brain-injury centers. The benefits of TPN (early administration, uniform tolerance, and no malabsorption) must be balanced by several actual and potential risks, which have been lessened with the increase in nutrition support teams. The first group of risks are mechanical: the risk of catheter sepsis, pneumothorax, and hemothorax. Other potential disadvantages of TPN are the potential for greater hyperglycemia and hyperosmolarity than is seen with enteral alimentation due to greater insulin resistance. 1:3 While there is no evidence of better protein utilization with TPN than enteral alimentation, enteral feeding itself may reduce infection rates.8,14,15 The gut, when not used for nutrition, has been implicated as the source of septic complications in patients with multiple trauma and enteral rather than parenteral feedings may produce posttraumatic septic morbidity.15-1? Early enteral feeding has been reported experimentally to diminish the ability of bacteria and fungi to translocate out of the gut after injury.&dquo; Additionally, early enteral intake within hours of injury has been reported in both basic and clinical studies to diminish the hypermetabolic response to injury.19-21 Finally,1 TPN is about twice as expensive as enteral feeding. Jejunal feeding has been found in this and other studies to be equivalent to TPN in the ability to deliver calories and nitrogen early after injury, but application to brain-injured patients has been limited.’,&dquo; Grahm and colleagues‘3 have reported improved caloric and nitrogen intake, improved nitrogen balance, and reduced infectious complications in 15 brain-injured patients fed jejunally, as compared to 14 patients fed gastrically. These investigators achieved full caloric intake by day 6 by gastric enteral feeding and by day 3 postinjury in the jejunally fed group using nasojejunal feeding tubes.’; The technology to use percutaneously inserted intestinal tubes in these patients has only recently been available. Percutaneous endoscopic gastrostomy has been performed since the early 1980S.21 Use of a rotational bed (Kinetic Concepts, Inc, San Antonio, TX) allows patients to be placed in a position similar to that used for standard endoscopy and permits this procedure to be performed at the bedside. The primary obstacle to enteral feeding has been delayed gastric emptying associated in part with elevation of intracranial pressure.:2.; Development of combined feeding attachments for gastric decompression and simultaneous small intestinal feeding overcame this obstacle to enteral feeding in brain injury. In addition to routine ease of insertion in the intensive care unit (24/27) and infrequent migration of tubes out of the small intestine (2/ ~ i ), the gastric port was used
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302 for
feedings
as soon as
gastric emptying abnormalities
subsided (2-3 weeks). A problem with erosion of the abdominal wall by the bumper of Sacks-Vine tubes did not harm patients and was alleviated by use of the Caluso PEG. As
more data become available, there is increasing emphasis on feeding the brain-injured patient early in the hope of reducing infections, reducing hypermetabolism, and possibly reducing neurologic complications. Small intestinal feeding allows very early nutrition of all patients except those with serious abdominal trauma and those in barbiturate coma. Inasmuch as many patients with severe brain injury are in the operating room for craniotomy, repair of associated injury, or ventriculostomy placement, surgical placement of a gastric/jejunal
tube at that time is convenient. Regardless of whether tubes are inserted nasojejunally,
by percutaneous endoscopic gastrojejunostomy, or by surgically placed jejunostomy, feeding via small intestine offers several potential advantages over TPN or gastric feeding in management of brain injury. Whether the enteral or parenteral route, or a combination of the two, is best for the brain-injured patient will require further studies. We conclude that the endoscopic approach to these patients, when possible, is an important advance in this patient population. ACKNOWLEDGMENTS
The authors thank Marianne Peterson for her artistic for her dietary assistance, and the nurses of the Neuroscience ICU for helping to make this study possible. This research was supported by grant 524402 from the Department of Education, National Institute of Disability and Rehabilitation to Dr Guy L. Clifton.
contribution, Mary Williams, RD,
REFERENCES 1. Clifton GL, Robertson CS, Contant CF: Enteral hyperalimentation in head injury. J Neurosurg 62:186-193, 1985 2. Clifton GL, Robertson CS, Grossman RG, et al: The metabolic response to severe head injury. J Neurosurg 60:687-696, 1984 3. Grahm TW, Zadrozny DB, Harrington T: The benefits of early
in the head-injured patient. Neurosur25:729-735, 1989 Rapp RP, Young B, Twyman D, et al: The favorable effect of early
jejunal hyperalimentation gery
4.
parenteral feeding
on
survival in
head-injured patients.
J Neuro-
58:906-912, 1983 5. Young B, Ott L, Twyman D, surg
et al: The effect of nutritional support head injury. J Neurosurg 67:668-676, 1987 6. Norton JA, Ott LG, McClain C, et al: Intolerance to enteral feeding in the brain-injured patient. J Neurosurg 68:62-66, 1988 7. Ott L, Phillips R, Young B, et al: Altered gastric emptying after head injury and its relationship to feeding intolerance. JPEN on
outcome from
severe
13(suppl 1):138, 1989 S, Dellinger EP, Wertz MJ, et al: Enteral versus parenteral nutritional support following laparotomy for trauma: A randomized prospective trial. J Trauma 26:882-889, 1986 McArdie AH, Palmason C, Morency I: A rationale for enteral feeding as the preferable route for hyperalimentation. Surgery 90:616-623, 1981 Muggia-Sullam M, Bower RH, Murphy RF, et al: Postoperative enteral versus parenteral nutritional support in gastrointestinal surgery. Am J Surg 149:106-112, 1985 Clifton GL, Robertson CS, Choi SC: Assessment of nutritional requirements of head-injured patients. J Neurosurg 64:895-901,
8. Adams
9.
10.
11.
1986 12. Ward
MWN, Owens CWI, biological samples by use
Rennie MJ: Nitrogen estimation in of chemiluminescence. Clin Chem
26:1336-1339, 1980 R, Schultz Y, Lemarchand T, et al: Hormonal and metabolic changes following severe head injury or non-cranial injury. JPEN 13:5-12, 1989 14. Dempsey DT, Mullen JL: Parenteral (glucose or glucose-lipid) vs enteral repletion in malnourished primates: A controlled crossover study. Am J Clin Nutr 45:1526-1532, 1987 15. Moore FA, Moore EE, Jones TN, et al: TEN versus TPN following major abdominal trauma-reduced septic morbidity. J Trauma 29:916-923, 1989 16. Border JR, Hassett J, LaDuca J, et al: The gut origin septic states in blunt multiple trauma (ISS 40) in the ICU. Ann Surg 206:427448, 1987 17. Kudsk KA, Stone JM, Carpenter G, et al: Enteral and parenteral feeding influences mortality after hemoglobin-E coli peritonitis in 13. Chiolero
=
normal rats. J Trauma 23:605-609, 1983 18. Inoue S, Epstein MD, Alexander JW: Prevention of yeast translocation across the gut by a single enteral feeding after burn injury. JPEN 13:565-571, 1989 19. Dominioni L, Trocki O, Mochizuki H, et al: Prevention of severe postburn hypermetabolism and catabolism by immediate intragastric feeding. J Burn Care Rehab 5:106-112, 1984 20. Jenkins M, Gottschlich M, Alexander JW, et al: Effect of immediate enteral feeding on the hypermetabolic response following severe burn injury. JPEN 13(suppl 1):128, 1989 21. Mochizuki H, Trocki O, Dominioni L: Mechanism of prevention of postburn hypermetabolism and catabolism by early enteral feeding. Ann Surg 200:297-310, 1984 22. Ponsky JL, Gauderer MWL: Percutaneous endoscopic gastrostomy. Gastrointest Endosc 27:9-11, 1981 23. Garrick T, Mulvihill S, Buack S, et al: Intracerebroventricular pressure inhibits gastric antral and duodenal contractility but not acid secretion in conscious rabbits. Gastroenterology 95:26-31, 1988
Downloaded from pen.sagepub.com at The University of Iowa Libraries on June 1, 2015
the Divisions of Gastroenterology and Neurosurgery, and the Department of Pathology, Commonwealth University, Medical College of Virginia Hospitals, Richmond, Virginia
Support Seruice,
Virginia
ABSTRACT. Twenty-seven patients in a series of 52 patients with severe brain injury (Glasgow Coma Scale score ≤8) underwent insertion of intestinal feeding tubes at the bedside. The technique required endoscopy with externalization of gastric and intestinal ports through the abdominal wall. Feedings were begun through the intestinal tube with Vital HN within 4 hours of its insertion with simultaneous gastric decompression via the gastric tube. Tubes were placed 2.3 (range 0-5) days after injury. Full caloric intake (3020 kcal/24 h) was achieved by 6.8 (range 2-8) days after injury to 4.2 (range 2-8) days after placement of the feeding tube. Only 1 patient failed to tolerate feedings immediately after tube insertion. Technical inability to insert the tubes occurred in 3 patients and the intestinal tube migrated into the stomach in 2 patients; diarrhea occurred in only 1 patient. With this technique, it was possible to deliver
an average daily intake of 1.2 g/kg of protein in 8-day balance periods beginning at the time of tube insertion. These data included 3- to 4-day periods in which feedings were steadily increased. In 16 patients in whom nitrogen balance was measured for 8-day balance periods, average nitrogen balance was -5.7 (range -11.3 to +3.5) g/24 h. The reduction in nitrogen loss by this technique appears equal to or superior to either gastric feeding or TPN. This technique provides the ability to enterally feed a high proportion of brain-injured patients (except those in barbiturate coma) very early after injury using a bedside procedure. It is concluded that intestinal feeding is the procedure of choice for the nutritional management of the Journal of Parenteral and Enteral Nubrain-injured patient. (
A number of different feeding methods have been tested to improve nutritional management of brain-injured patients, since description of the metabolic response to brain injury.1-4 The two goals of management have been early caloric and protein replacement and reduction of negative nitrogen balance. Achievement of full caloric replacement within 3-5 days by total parenteral nutrition (TPN) or jejunal feeding has been associated with more rapid neurologic recovery and with reduced infectious complications.3-5 Gastric enteral feeding in brain-injured patients has not been as satisfactory as TPN or jejunal feedings.3°4°6°’ In previous work we compared nitrogen balance achieved by enteral infusion of two large quantities of high protein content formulas in 20 patients. Considerable attention to details of feeding with individualized adjustment of feeding rates was required. In this study 20% of patients did not tolerate gastric enteral feedings due to diarrhea or delayed gastric emptying, and full caloric intake was achieved in the rest on the average 8 days after injury.1 Other investigators have shown radiographically in severely brain-injured patients a defect in gastric emptying lasting 2 weeks, found intolerance to enteral feeding at 10 days postinjury in 50% of patients, and reported aspiration pneumonitis in 22% of patients fed gastrically.6,7 The best efforts of Young et aP at gastric feeding
resulted in full caloric replacement at 12 days after injury and lower nitrogen balances than they achieved with TPN. For these reasons, most brain injury centers have simply used TPN for 2-3 weeks after injury and then converted to gastric feeding.
Reprint requests: Donald F. Kirby, MD, Box 711, MCV Station, Richmond, VA 23298-0711.
trition 15 :298-302, 1991)
Jejunal feedings have been increasingly used, rather than TPN, after gastric and duodenal surgery.8-10 Jejunal feeding in brain-injured patients by nasojejunal tubes has been reported to supply full caloric intake within 3 days of brain injury.3 We and others have found radiographic insertion of nasojejunal tubes to be difficult and migration of the tubes out of the jejunum and into the stomach to be frequent.6 To test another approach, 27 of a series of 52 patients with severe brain injury underwent endoscopic placement at the bedside of a percutaneous endoscopic gastrostomy (PEG) tube with a smaller feeding tube that has both gastric and intestinal ports (PEG/ J). The time to full caloric replacement was measured in these 27 patients. Nitrogen balance was measured in 16 patients to assess the outcome of intestinal feedings as compared to previously published data with parenteral and gastric feedings in brain-injured patients. MATERIALS AND METHODS
Population and Management Fifty-two patients with severe brain injury (Glasgow Coma Scale [GCS] scores8) on admission were admitted to Medical College of Virginia Hospitals from January through December 1989. Patients underwent early intu-
Patient
Downloaded from pen.sagepub.com at The University of Iowa Libraries on June 1, 2015
299
bation, and computerized tomographic
scans were
per-
formed within 1 hour of admission with immediate
cra-
niotomy for those with mass lesions. Intracranial pressure (ICP) monitors were placed in all patients. Patients were managed on rotational beds (Kinetic Concepts, Inc, San Antonio, TX). Intracranial pressure ~20 mm Hg 35 mm was treated first by hyperventilation (PaCo2 Hg) and ventricular drainage and, if not controlled by these measures, mannitol (0.25 g/kg) was administered. =
was used to maintain blood levels of 70to treat elevated ICP in four patients who had
Pentobarbital 90
mg/L
ICP uncontrollable by other means. Swan-Ganz catheters were placed and pulmonary capillary wedge pressure maintained a12 mm Hg by infusion of crystalloid when barbiturates or mannitol were used. Jejunal feeding tubes were placed in 30 patients. PEG/ J tubes were inserted in 27 patients, a nasojejunal tube in 1, and surgical placement of a PEG/J tube in 2. Of the remaining 22 patients, 7 were nutritionally managed with TPN, 6 with nasogastric feedings, and 9 patients with GCS of 3 and/or difficult-to-control increased ICP had no nutritional management. These latter 9 patients died within 7 days of injury.
Management of PEG/J Tubes Nasogastric or orogastric tubes were placed on admission in all patients and kept to intermittent suction. Only patients who had had a negative diagnostic paracentesis were eligible for placement of a PEG tube with small intestinal feeding tube (PEG/J). As soon as possible and always within 5 days of injury (mean 2.3, range 0-5 days), 27 patients underwent placement of PEG/J tubes. After routine endoscopic evaluation for exclusion of significant ulcer disease, a PEG catheter (size 18-28 French) was placed into the stomach. A PEG/J tube was then guided through the established PEG and the jejunal catheter pulled with a grasping forceps into the small intestine. An x-ray was obtained to verify the position of the small intestinal tube. Figure 1 illustrates the PEG/J tube. The following feeding tubes were used: 18 Fr SacksVine PEG with 10 Fr G/J Tube 14/26 (54%) (Ross Laboratories, Columbus, OH), 22 Fr Caluso PEG with 10 Fr G/J Tube 1/26 (4%) (Superior Biosystems Inc, Cumberland, RI), and 28 Fr Caluso PEG with 12 Fr G/ J 11/26 (42%). After placement, water was infused over the first 2-4 hours and if no significant intolerance occurred, then full-strength isotonic feedings were begun at 50 mL/h and increased by 25 mL/12 h until the desired rate was reached. Vital HN, which contains 10% fat, 74% carbohydrate, and 16% hydrolyzed protein, was fed by continuous infusion. Vital HN has 6.7 g of nitrogen per liter with a nonprotein calorie to nitrogen ratio of 125:1. Caloric requirements for each patient were estimated by previously published formulas. 11 Intermittent gastric suction via the gastric port of the PEG/J tube was carried out throughout the period of intestinal feedings. Feedings . were stopped only for abdominal distention with the absence of bowel sounds as determined by physical examination or recovery of tube feeding via the gastric port
FiG. 1. Example of a PEG/J tube with the gastrostomy tube anchored in the stomach and the intestinal J-tube placed into the small intestine. Note the two ports on this tube: one for gastric suction and one for intestinal feeding.
of the PEG/J (indicating that the tube had slipped out of place). Most patients had methylene blue added to their tube feeding to facilitate rapid identification of tube feeding refluxing into the stomach or suspicious gastric drainage was monitored for glucose indicating the presence of tube feeding in those patients whose tube feeding was not colored. Absent bowel sounds alone did not necessitate discontinuation of feedings, but feedings were not administered to patients in barbiturate coma. After an average of 2 weeks of intestinal feedings, the gastric port was used for nourishment. After it was established that gastric feedings were tolerated, the intestinal tube was removed from the PEG tube and a feeding adaptor placed on the tube to allow further feeding into the stomach. Nutritional Measurement
All urine was collected daily via a Foley catheter in containers with 30 mL of 1 mol/L hydrochloric acid. Urine was measured and mixed by research personnel and urinary nitrogen measured by the chemilumines-
technique (Antek Instruments, Houston, TX). 12 g/L of protein, the coefficient of variation of this technique was 4.34%. Balance periods of continuous urine collection were begun on the first to third day after injury and continued for 5-13 days. cence
At 6.9
RESULTS
The characteristics of the 52 patients in this study including GCS, primary diagnosis, and outcome are shown in Table I. Patients were eligible for PEG/J placement if they had no intraabdominal insult that precluded safe endoscopic placement of the PEG/J tube or contraindication such as neck instability or significant facial fractures that made oral intubation with an endoscope impossible. Patients not fed jejunally are divided into four groups: those managed by TPN, those managed
Downloaded from pen.sagepub.com at The University of Iowa Libraries on June 1, 2015
300 TABLE I Patients’ characteristics
*
Primary diagnosis: DBI, diffuse brain injury; EDH, epidural hematoma; SDH, subdural hematoma; ICH, intracerebral hematoma. GR, good recovery; MD, moderate disability; SD, severe disability; V, vegetative; D, dead.
t Outcome:
by nasogastric feedings,
those without nutritional
agement, and those in whom PEG/J tubes
were
man-
placed
but not used acutely. In 9 patients, PEG/J tubes were inserted but, because of increased ICP requiring barbiturate coma, acute renal failure limiting fluid intake, or early death, they were not used for management. Except for patients with no nutritional management, who were the oldest and most severely injured, the remainder are similar in injury severity and outcome to patients who underwent jejunal feeding. Differences in outcome among groups appear to reflect differences in injury severity, not mode of nutritional management. Table II gives caloric data for each of 21 patients who underwent insertion of a jejunal feeding tube with nutritional management and gives nitrogen balance data for 16 randomly selected patients in this group. The timing of PEG/J tube insertion is shown. Also shown is the time after admission and time after PEG/J tube insertion by which full caloric intake based on calculated requirements was achieved. Maximal levels of caloric and nitrogen intake are also shown in Table II. PEG/J tubes were Caloric data
on
inserted
a mean of 2.3 (range 0-5) days from injury and 4.2 (range 2-8) days were required to reach full caloric intake. This resulted in full intake 6.8 (range 3-12) days after injury. The average time during which the nitrogen balance was measured continuously was 7.7 (range 5-12) days. The mean caloric intake for the balance period was 1867 kcal/24 h and ranged from 1060 kcal/24 h to 2640 kcal/24 h. At maximal caloric intake 2400-3360 kcal/24 h, with an average of 3020 kcal/24 h, was administered. Average protein intake for the balance period was 1.2 g/ kg per 24 hours. Mean nitrogen intake for this balance period was 12.5 (range 7.11-18.5) g/24 h. Assuming 2 g for fecal and cutaneous nitrogen loss, total nitrogen excretion was 17 (range 7-24) g/24 h, resulting in a nitrogen balance of -5.7 (range -11.3 to +3.5) g/24 h. Balance periods incorporate 4-day periods when intestinal alimentation was being steadily increased and,
caloric and nitrogen intakes represent days of low intake early in the balance period and higher intake later. PEG/J tube insertion required a skilled endoscopist.
therefore, an
mean
average of
TABLE II those patients fed via jejunal feeding tube
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301
After insertion, the majority of intestinal tubes were in the second portion of the duodenum by radiographic evaluation and the remainder in the jejunum. Either location resulted in satisfactory feeding tolerance. Difficulties with PEG/J tube placement were an inability to pass the second portion of the duodenum with the jejunal feeding tube in two patients and inability to pass an edematous pharynx in another. These patients were all treated with TPN. In seven cases, the internal bumper used to anchor the Sacks-Vine tubes against the stomach eroded the abdominal wall at 11-36 weeks after injury. This led to abandonment of use of the Sacks-Vine tube. Use of the Caluso PEG tube eliminated this complication. In two cases, the intestinal tube slipped back into the stomach and in one case gastroduodenal reflux resulted in the tube migrating into the duodenal bulb. In two cases, the tube became occluded due to Kayexalate or crushed medications. One was reopened and the other was endoscopically replaced. Absorption of feedings must have been total inasmuch as there was no stool at all for the first 2 weeks after PEG/J tube insertion except for one patient who developed diarrhea. Abdominal distention necessitated discontinuing feedings in only one patient. DISCUSSION
Our purpose was to establish whether intestinal feeding via a catheter percutaneously inserted at the bedside resulted in a high level of tolerance of feedings early after injury in patients with severe brain injury. We further wished to establish whether nitrogen balance with such an approach was at least equivalent to values previously established for gastric feeding and TPN. We did not attempt to establish improvement in outcome by this approach. We achieved full intake by the seventh day after injury with tube insertion on the second day. Importantly, we also observed intolerance of feedings in only 1 of 21 patients not in barbiturate coma. Like Grahm et al,3 we found with use of a small intestinal feeding tube that ability to deliver calories and to reduce nitrogen loss early after injury were equal or superior to data reported with gastric enteral feeding or TPN in brain-inured patients. Nitrogen balance by PEG/J tube was -5.7 g/24 h with 12.4 g/24 h nitrogen intake, comparing favorably with published data. Nitrogen balance data in our previous studies of gastric enterally fed braininjured patients showed nitrogen balances of -9.2 g/24 h with 17.6 g/24 h nitrogen intake in balance periods
beginning on day 8.1 Young et al5 reported negative nitrogen balance of -6 g/24 h in the first week after injury with 15 g/24 h nitrogen intake by TPN. Investigators have attempted to improve nutritional management of the brain-injured patient by three different routes of feeding: parenterally with TPN and enterally by gastric or small intestinal feeding. We previously used gastric enteral feeding, finding that 20% of patients would not tolerate enteral feeding until the second week after injury. In this study, large amounts of calories and nitrogen could be delivered by day 8 after injury in those patients who tolerated gastric enteral alimentation the first week.
in
Young and colleagueS5 were able to achieve full caloric intake at 12 days after injury by gastric enteral feedings with their best effort, but 35% of patients did not tolerate gastric feedings by day 7 after injury. The difficulties in consistently feeding patients early after brain injury by gastric enteral feeding have been elucidated by Ott et al,’ who showed radiographically that 7 of 12 brain-injured patients had delayed gastric emptying of liquids during the first postinjury week. TPN for the first 2 weeks after injury has been the most widely used feeding technique in brain-injury centers. The benefits of TPN (early administration, uniform tolerance, and no malabsorption) must be balanced by several actual and potential risks, which have been lessened with the increase in nutrition support teams. The first group of risks are mechanical: the risk of catheter sepsis, pneumothorax, and hemothorax. Other potential disadvantages of TPN are the potential for greater hyperglycemia and hyperosmolarity than is seen with enteral alimentation due to greater insulin resistance. 1:3 While there is no evidence of better protein utilization with TPN than enteral alimentation, enteral feeding itself may reduce infection rates.8,14,15 The gut, when not used for nutrition, has been implicated as the source of septic complications in patients with multiple trauma and enteral rather than parenteral feedings may produce posttraumatic septic morbidity.15-1? Early enteral feeding has been reported experimentally to diminish the ability of bacteria and fungi to translocate out of the gut after injury.&dquo; Additionally, early enteral intake within hours of injury has been reported in both basic and clinical studies to diminish the hypermetabolic response to injury.19-21 Finally,1 TPN is about twice as expensive as enteral feeding. Jejunal feeding has been found in this and other studies to be equivalent to TPN in the ability to deliver calories and nitrogen early after injury, but application to brain-injured patients has been limited.’,&dquo; Grahm and colleagues‘3 have reported improved caloric and nitrogen intake, improved nitrogen balance, and reduced infectious complications in 15 brain-injured patients fed jejunally, as compared to 14 patients fed gastrically. These investigators achieved full caloric intake by day 6 by gastric enteral feeding and by day 3 postinjury in the jejunally fed group using nasojejunal feeding tubes.’; The technology to use percutaneously inserted intestinal tubes in these patients has only recently been available. Percutaneous endoscopic gastrostomy has been performed since the early 1980S.21 Use of a rotational bed (Kinetic Concepts, Inc, San Antonio, TX) allows patients to be placed in a position similar to that used for standard endoscopy and permits this procedure to be performed at the bedside. The primary obstacle to enteral feeding has been delayed gastric emptying associated in part with elevation of intracranial pressure.:2.; Development of combined feeding attachments for gastric decompression and simultaneous small intestinal feeding overcame this obstacle to enteral feeding in brain injury. In addition to routine ease of insertion in the intensive care unit (24/27) and infrequent migration of tubes out of the small intestine (2/ ~ i ), the gastric port was used
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302 for
feedings
as soon as
gastric emptying abnormalities
subsided (2-3 weeks). A problem with erosion of the abdominal wall by the bumper of Sacks-Vine tubes did not harm patients and was alleviated by use of the Caluso PEG. As
more data become available, there is increasing emphasis on feeding the brain-injured patient early in the hope of reducing infections, reducing hypermetabolism, and possibly reducing neurologic complications. Small intestinal feeding allows very early nutrition of all patients except those with serious abdominal trauma and those in barbiturate coma. Inasmuch as many patients with severe brain injury are in the operating room for craniotomy, repair of associated injury, or ventriculostomy placement, surgical placement of a gastric/jejunal
tube at that time is convenient. Regardless of whether tubes are inserted nasojejunally,
by percutaneous endoscopic gastrojejunostomy, or by surgically placed jejunostomy, feeding via small intestine offers several potential advantages over TPN or gastric feeding in management of brain injury. Whether the enteral or parenteral route, or a combination of the two, is best for the brain-injured patient will require further studies. We conclude that the endoscopic approach to these patients, when possible, is an important advance in this patient population. ACKNOWLEDGMENTS
The authors thank Marianne Peterson for her artistic for her dietary assistance, and the nurses of the Neuroscience ICU for helping to make this study possible. This research was supported by grant 524402 from the Department of Education, National Institute of Disability and Rehabilitation to Dr Guy L. Clifton.
contribution, Mary Williams, RD,
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