Although all of the guidelines acknowledged nausea and vomiting as side effects of medications used in treating TBI, none specifically addressed their impact on weight in the longer term or a need for referral for complete nutritional assessment by a registered dietitian.
Medical and nutrition care in the field, military treatment facilities, VA medical facilities, and in the home environment after discharge from medical treatment facilities are increasingly guided by EBGs. The TBI-specific EBGs currently available are extremely limited in their discussion of nutrition assessment, nutrition-specific interventions, and nutrition monitoring and evaluation criteria. The generic critical-illness EBGs that may apply do not specifically identify any unique nutritional concerns of TBI patients. There is general agreement among the existing EBGs on the need to determine energy requirements and to meet those needs in acute TBI early in treatment, the preference of use of enteral nutrition over parenteral nutrition when possible (in U.S. guidelines), and the need to maintain serum glucose control. The consensus is less clear on the use of antioxidants and immune-enhancing formulas, the method or frequency of determining energy requirements, and the percentage of energy needs that should be met in acute TBI treatment.
The body of research to support clinical practice guidelines specific to the nutrition care of TBI patients is extremely limited. To aid those preparing such guidelines, specific questions of interest for future research are included in Appendix C, Table B-3. The questions are based on the recommendations of the committee (Chapters 6–16) and have been tabulated in the Population, Intervention, Comparator, Outcome format. The general topics are:
Identification of specific nutrients, dietary supplements, and food components that promise benefits in providing resilience or treating TBI and for which nutritional status should be assessed in the military population.
Determination of optimal feeding regimens (e.g., energy needs and sources, route of administration, novel nutrition therapies) at various points (e.g., less than 24 hours, 24 hours to 7 days, post 7 days, chronic home care) within the nutrition care treatment cycle for varying levels of severity of TBI injury.
Identification of biomarkers and assessment indicators to reflect level of mitochondrial function and inflammatory responses.
RECOMMENDATION 2-1. Evidence-based nutrition guidelines specific for severe TBI should be updated. These guidelines should address unique nutritional concerns of severe TBI when different from generic critical-illness nutrition guidelines (e.g., meeting energy needs and benefits of specific nutrients, food components, or diets). In addition, current guidelines to manage mild and moderate TBI should include recommendations for nutritional interventions. The guidelines should be developed in a collaborative manner with the various key stakeholders (e.g., ADA, VA, DoD).
ADA (American Dietetic Association). 2006. Critical illness evidence-based nutrition practice guideline. American Dietetic Association. http://www.adaevidencelibrary.com/topic.cfm?cat=2799 (accessed October 26, 2010).
ADA. 2010. ADA method of creating evidence-based nutrition practice guidelines. American Dietetic Association. http://www.adaevidencelibrary.com/category.cfm?cid=16&cat=0&library=EBG (accessed October 26, 2010).