B. E. Haac1, R. Van Besien1, R. Jenkins1, A. Geyer2, J. Diaz1, D. Stein1 1University Of Maryland,R Adams Cowley Shock Trauma Cener,Baltimore, MD, USA 2Air Force Institute Of Technology (AFIT/ENC),Wright-Patterson AFB, OHIO, USA
Introduction: Nutrition is an important component of support for critically-ill trauma patients who often present in a state of catabolic stress but there is limited recent research on this topic specific to trauma patients. We sought to examine nutritional practices in a critically-ill trauma population and to identify baseline factors and outcomes associated with timing, content and route of nutrition.
Methods: We conducted a retrospective review of adult critically-ill trauma patients admitted to the intensive care unit (ICU) for >72 hours. A multivariable regression model was built for each nutritional variable and outcome variable. Outcomes evaluated include number of operative trips, hospital and ICU length of stay (LOS), ventilator days, mortality, discharge destination and hospital-acquired infections.
Results: 683 patients (mean ISS 24.4) were included. 461 patients received tube feeds within the first 7 days of admission. Two-thirds (n=297, 64%) of these were initiated on early enteral tube feeding within 48 hours. Injury pattern was associated with timing of nutrition initiation, time to goal tube feed rate and percent of goal calories and protein received. Specifically, severe head injury (brain AIS=5) was independently associated with reaching a goal tube feed rate (aOR 3.1, P<0.01) and receiving a greater percent of goal calories (aOR 2.1, p=0.01) in the first 48 hours of admission whereas patients without head injury (brain AIS=0) were less likely to initiate nutrition within 24 hours of admission (aOR 0.3, p<0.01). Higher admission GCS was also associated with decreased odds of reaching goal tube feeds within 24 hours (aOR 0.6, p<0.01). Later initiation of enteral nutrition after 48 hours was associated with increased ICU LOS (aOR 1.4, p<0.01) and more ventilator days (aOR 1.6, p<0.01) in all patients and increased pneumonia rates in patients who required gastrointestional (GI) surgery for their injury (aOR 15.7, p=0.02). Increased percent of goal nutrition received in the first 48 hours was associated with more ventilator days (aOR 2.8, p<0.01) and longer ICU LOS (aOR 1.7, p<0.01). Increased percent of goal nutrition received in the first 7 days was associated with development of urinary tract infection (UTI) (aOR 5.4, p<0.01). Gastric tube feeds were associated with lower bacteremia incidence (aOR=0.4, p=0.01) and longer ICU LOS (aOR 1.2, p<0.01). There was no association of nutrition variables with mortality.
Conclusion: Injury pattern, especially presence of brain injury, may be predictive of ability to initiate early enteral nutrition, time to goal feeds and percent of goal nutrition received. Benefits of early initiation may include decreased LOS and ventilator days and reduced pneumonia rates in patients requiring GI surgery. Trophic feeds may be less likely to result in UTI, and gastric feeds may have a protective role in prevention of bacteremia.