This report emphasizes the importance of nutrition not only to augment overall defensive mechanisms against the effects of TBI but also as postinjury treatment to lessen the acute and subacute effects of TBI. The committee found that the majority of clinical guidelines for TBI do not specifically address optimal nutritional support for TBI. Based on the literature searches the committee concluded that conducting a review of the nutrition approaches to improve long-term effects of TBI, which was part of the initial task and later excluded because of financial constraints, would also be important (see also workshop papers by Metzger, Gomez-Pinilla, and Sands in Appendix C).
The recommendations were reached by consensus and are a reflection of the gap in data about the efficacy of most of the nutrition approaches reviewed. For this reason, except for early feeding of severe cases, the committee thought it premature to direct DoD to adopt any of them at this time. For the approaches that are supported by enough preclinical and, in some cases, clinical data, the committee sees the potential benefits for TBI patients and reached consensus about research needed in some promising areas. The report includes recommendations for research on the specific nutrition approaches that are promising and warrant further investigation. The research recommended will serve to confirm published results and to refine the protocols (i.e., optimal route of administration, timing, and dose).
The committee made recommendations for updating the evidence-based guidance for severe TBI with the provision of early feeding (Box S-1) as well as for research on continuing the development of animal models and the identification of biomarkers (Box S-2), on assessing nutritional status and intake of military populations (Box S-3), and on promising areas of nutrition research (Boxes S-4 and S-5). Finally, the committee includes a general recommendation to develop and update evidence-based guidance for TBI in the future, as more evidence about the value of nutritional interventions becomes available (Box S-6). The committee offers here its reflections on the prioritization of research based on its opinion of the likelihood of positive results for lessening the effects of TBI. Research on interventions for which human trials to explore the efficacy of improving the outcomes of TBI already exist or are ongoing have been presented as “most promising research” (Box 17-4). Research on interventions for which animal studies in TBI or human studies in associated conditions have shown improvements in outcomes are presented as “other research” (Box 17-5). DoD is encouraged to conduct the research internally, to support extramural research, or to collaborate with others in order to obtain answers more effectively.
The committee recognizes that conducting clinical research on TBI is extremely complex and that the understanding of the differences in pathophysiology between mild and severe
Standardize the Provision of Energy and Protein to Patients with Severe TBI
RECOMMENDATION 6-1. The committee recommends that evidence-based guidelines include the provision of early (within 24 hours after injury) nutrition (more than 50 percent of total energy expenditure and 1–1.5 g/kg protein) for the first two weeks after injury. This intervention is critical to limit the intensity of the inflammatory response due to TBI, and to improve outcome.