title: Tolerance and efficacy of enteral nutrition in traumatic brain-injured patients induced into barbiturate coma.
abstract: BACKGROUND
  There is a paucity of data evaluating the efficacy of nutrition support in traumatic brain-injured patients induced into barbiturate coma for refractory intracranial hypertension. Our objective was to evaluate the efficacy of enteral nutrition in a select group of trauma patients.
  
  
  METHODS
  Prospective data were collected on severe traumatic brain-injured patients over a 4-year period. Patients were stratified by whether or not they were induced into a barbiturate coma. Barbiturate coma was defined as per American Association of Neurological Surgeons (AANS) guidelines. All patients were initially fed via the enteral route via a nasogastric feeding tube. Patients who did not tolerate feedings within 48 hours started receiving prokinetic agents. Feeding tolerance was defined as ability to tolerate enteral feedings with <150 mL of gastric residuals every 6 hours for >72 hours.
  
  
  RESULTS
  Fifty-seven patients were induced into a barbiturate coma. All were victims of blunt-force trauma. Forty-two of 57 (74%) patients were men, with a mean age of 37+/-12 years and a mean injury severity score of 24+/-10. Thirty-eight of the 57 (67%) patients had an isolated traumatic brain injury. All 57 patients failed enteral nutrition via the nasogastric route after the first 48 hours of nutrition initiation after barbiturate coma was fully achieved by protocol criteria. Prokinetic agents demonstrated no improvement in feeding tolerance after the subsequent 48-72 hours. Of the 12 patients who had a postpyloric feeding tube placed, only 25% tolerated enteral nutrition for >48 hours.
  
  
  CONCLUSIONS
  Patients with traumatic brain injury induced into barbiturate coma develop a significant ileus that is refractory to prokinetic agents. Only a marginal improvement is seen when the postpyloric route is obtained. Early parenteral nutrition should be considered in this patient population.
authors.affiliation: R. Adams Cowley Shock Trauma Center, Division of Clinical and Outcomes Research, University of Maryland School of Medicine, Baltimore, Maryland 21201, USA. gbochicchio@umm.edu
authors.forename: Grant V
authors.initials: GV
authors.lastname: Bochicchio
authors.forename: Kelly
authors.initials: K
authors.lastname: Bochicchio
authors.forename: Shelley
authors.initials: S
authors.lastname: Nehman
authors.forename: Colleen
authors.initials: C
authors.lastname: Casey
authors.forename: Penny
authors.initials: P
authors.lastname: Andrews
authors.forename: Thomas M
authors.initials: TM
authors.lastname: Scalea
mesh_terms: D000328:Adult; D001463:Barbiturates / Q000494:pharmacology; D001930:Brain Injuries / Q000378:metabolism / Q000628:therapy*; D003128:Coma / Q000139:chemically induced; D002149:Energy Intake / Q000502:physiology*; D004734:Energy Metabolism / Q000502:physiology*; D004750:Enteral Nutrition; D005260:Female; D006801:Humans; D015601:Injury Severity Score; D007427:Intracranial Pressure; D007441:Intubation, Gastrointestinal / Q000379:methods; D008297:Male; D009751:Nutritional Requirements; D011446:Prospective Studies; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D001463:Barbiturates