ety, the American Association of Neuroscience Nurses (AANN), the Department of Defense (DoD), and the U.S. Department of Veterans Affairs (VA) (ADA, 2006; Bratton et al., 2007; Kattelmann et al., 2006; Knuth et al., 2005; McClave et al., 2009; VA/DoD, 2009). The following section summarizes the nutrition components of these EBGs. For this chapter, the EBGs were divided into two types: those for patients with severe TBI in the acute phase who are in the intensive care unit (ICU) critical-care setting, and those for patients with mild TBI, who are more likely to be outpatients.

EBGS FOR SEVERE TBI IN THE ACUTE STAGES

DoD’s Guidelines for the Field Management of Combat-Related Head Trauma (Knuth et al., 2005) address assessment of oxygenation and blood pressure, Glasgow Coma Scale, airway, ventilation, fluid treatment, pain management and sedation, triage for transport, and brain-targeted therapy. The only nutrition-related content is the discussion of assessment of nausea as a side effect of pain medication. Nutrition needs are not specifically addressed.

In contrast, other guidelines do recognize the importance of nutrition to accelerate progress in trauma patients. For example, the SCCM/ASPEN Guidelines for Provision and Assessment of Nutrition Support Therapy in the Adult Critically Ill Patient include recommendations for timing of initiation of enteral nutrition, use of parenteral nutrition, dosage of enteral feeding, monitoring, intolerance and adequacy of enteral nutrition, selection of appropriate enteral formulation, adjunctive therapies, and maximizing the efficacy of parenteral nutrition, as well as specific recommendations for the following medical conditions: pulmonary failure, renal failure, hepatic failure, acute pancreatitis, and end-of-life treatments (McClave et al., 2009).

The ADA Critical Illness Evidence-Based Nutrition Practice Guideline also includes recommendations for assessing nutritional issues in trauma patients. The recommendations address energy expenditure and needs, choosing enteral versus parenteral nutrition, timing of feeding, feeding tube site, use of immune-enhancing formulas, use of blue dye in enteral nutrition to detect aspiration, monitoring criteria and blood glucose control, and special considerations for persons with diabetes (Kattelmann et al., 2006).

The third edition of the Guidelines for the Management of Severe Traumatic Brain Injury from the Brain Trauma Foundation includes a recommended time frame for patients to attain adequate energy (within seven days), but concludes there is insufficient evidence to make recommendations on how to determine whether enteral or parenteral nutrition is preferred or whether the use of vitamin, minerals, or other supplements is warranted (Bratton et al., 2007).

Nursing interventions to maintain adequate nutrition are considered in the AANN EGB. The Nursing Management of Adults with Severe Traumatic Brain Injury guidelines include four main recommendations for adequate nutrition and glycemic control: timing of feeding, feeding tube site, the effect of certain agents on feeding tolerance, and the administration of intensive insulin therapy (Mcilvoy and Meyer, 2008).

Extracts from these guidelines related to nutrition appear in Appendix B, Table B-1. The following are key recommendations pertinent to TBI patients.

Estimating Energy Needs

The ASPEN and ADA EBGs discuss the need to determine energy requirements at the time of initiation of nutritional therapy. Both indicate that predictive equations should be



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