The Journal of Neurological and Neurosurgical Nursing 2017;6(1):33–38

Pielęgniarstwo
Neurologiczne i Neurochirurgiczne
THE JOURNAL OF NEUROLOGICAL AND NEUROSURGICAL NURSING
eISSN 2299-0321 ISSN 2084-8021 www.jnnn.pl Review

DOI: 10.15225/PNN.2017.6.1.6

Management of Nutrition in Neuro Intensive Care Patients

Stan odżywienia pacjentów Neurochirurgicznego Oddziału Intensywnej

Opieki Medycznej

Hatice Kaya, Nuray Turan, Gülsün Özdemir Aydın

Istanbul University, Florence Nightingale Faculty of Nursing,

Department of Fundamentals of Nursing, Turkey

Abstract

Neurosurgical patients present important metabolic alterations that trigger increased energy and protein expenditure.
The clinical condition in neuro patients associated with the use of sedatives, steroids, barbiturates and muscle-
relaxing drugs postpones the use of nutrients in these patients and, thus, complications, including infection and
longer hospitalization, may occur. Weight loss, negative nitrogen balance and immune dysfunction constitute a
characteristic response in neurosurgical patients. There is a strong relationship between adequate nutritional status
and recovery from critical illness. Improved nutritional status is associated with positive clinical outcomes. The
health care team, nurses in particular, play a major role in the management and maintenance of an optimal nutritional
status in patients who are in the neurosurgical clinic. This compilation aims at highlighting the fact that inadequate
nutrition is a serious problem which increases incidence of morbidity and mortality especially in neurosurgical
patients. The article also emphasises the importance of nursing assessment. (JNNN 2017;6(1):33–38)
Key Words: neuro patients, neurosurgery, nutrition

Streszczenie

U pacjentów Neurochirurgicznego Oddziału Intensywnej Opieki Medycznej występują istotne zmiany metaboliczne,
które powodują zwiększone wydatkowanie energii i białka. Neurochirurgiczny stan kliniczny w wyniku stosowania
środków uspokajających, steroidów, barbituranów i leków zwiotczających mięśnie opóźnia wykorzystanie składników
pokarmowych w tej grupie pacjentów, a zatem mogą wystąpić powikłania, w tym infekcje i dłuższa hospitalizacja.
Utrata masy ciała, ujemny bilans azotu i dysfunkcja układu odpornościowego stanowią charakterystyczną odpowiedź
u pacjentów neurochirurgicznych. Istnieje silny związek pomiędzy odpowiednim stanem odżywienia i regeneracją
po chorobie krytycznej. Dobry stan odżywienia jest związany z pozytywnymi wynikami klinicznymi. Zespół opieki
zdrowotnej, w szczególności pielęgniarki, odgrywają ważną rolę w utrzymaniu optymalnego stanu odżywienia u pacjentów
neurochirurgicznych. Przegląd ten ma na celu podkreślenie, że przeciętny stan odżywienia jest poważnym problemem
w kontekście zwiększonej zachorowalności i śmiertelności, zwłaszcza u pacjentów neurochirurgicznych. Artykuł
zwraca również uwagę na duże znaczenie oceny pielęgniarskiej. (PNN 2017;6(1):33–38)
Słowa kluczowe: pacjenci neurologiczni, neurochirurgia, odżywianie

Introduction modified dysphagia or mental status. Trauma, stroke,

head injury, spinal cord injury, brain tumor, degenerative
The patients in a neuro intensive care unit have disease (amyotrophic lateral sclerosis, multiple sclerosis,
individually nutrition-related requirements to the extent Parkinson’s, Alzheimer’s) or a mobility disorder (Guillain-
of their condition. It is a difficult task for the health team Barre syndrome, myasthenia gravis) are included among
to assess the nutritional requirements of individuals [1]. the general diagnoses made for the patients in a
Parenteral and enteral nutrition are often needed by neurosurgery intensive care unit. The destruction of
the patients who are neurologically disrupted with skeletal musculature and visceral protein reduction via

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insufficient oral intake, hyper-catabolism or dysmobility support, the rate of use of parenteral nutrition (PN) is
that are minor compared to disease course are potentially 12–71% while the rate of use of enteral nutrition (EN)
prompted by all of these conditions. Because of the is 33–92% [13]. The route may be less significant than
characteristics of their diseases and the invasive the scheduling of commencement of feeding which is
interferences that are necessary to support the non- also influential on the result. Namely, it has been
surgical patients while they are treated and recovered, demonstrated that early commencement of EN (by
even these patients may suffer from a hyper-catabolic 24–48 hours) decreases the trauma patients’ mortality
and hypermetabolic status [2–5]. rate [14].
The poor mortality rate and prognosis are often seen For the adult patients who are severely ill, nutritional
in the unconscious patients in the neuro intensive care support constitutes a part of the standard care. Various
unit. The requirement for nutrition support due to the factors might affect the selection of route for nutritional
risk of aspiration arising from respiratory muscle support for ordinary patients that stay in the intensive
weakness, failure to protect the airway and gastrointestinal care unit and don’t have any contraindications to enteral
reflux or gastroparesis and to dysphagia may be caused nutrition (EN) or parenteral nutrition (PN) [11,13].
by the damaged oral feeding that may also lead to the Nutritional support creates common benefits including
damaged appetite control centres in the brain. Cerebro- a decrease in translocation of bacteria, duration of stay,
vascular accident, traumatic brain damage or spinal cord complication ratio and catabolic response to damage
injury may severely result in neurologic damage that and also an increase in healing the wound, gastrointestinal
may also be caused by chronic degenerative courses. The permeability and clinical results. Nonetheless, there are
physiologic, metabolic and functional modifications in also negative impacts and risks of nutritional support.
a complicated series can be created by acute neurologic These complications concern mechanic and metabolic
damage such as intense traumatic brain injury [6]. troubles, gastrointestinal complications, infections and
Based on the severity of spinal cord injury, the patients tube insertion [12].
with such injury have hypo-metabolism and energy
consumption around 94% predicted by the Harris-
Benedict equation contrary to the patients having Assessment
traumatic brain injury. Since majority of physiologic
and metabolic alterations are seen in chronic phase of The data on the patients are gathered, confirmed and
disease not the acute stage, the cerebrovascular accident arranged in a systematic and constant way in the process
and degenerative neurological diseases (e.g., amyotrophic of assessment. These data show how the applications
lateral sclerosis, Parkinson’s disease and multiple sclerosis) that better health strengthens well-being or how a disease
vary. Despite the particular slight differences of neurologic or injury destructs health [9,15].
diseases, the feeding challenges constitute a frequent For neurosurgical patients, it is considerably
reason of malnutrition [6–8]. significant to perform an assessment of nutrition. An
The patients in the neurosurgery intensive care unit increase of 200% of ordinary values may be seen in
are confined to bed for a long time and they don’t have energy consumption. However, sufficient nutrition in
the capability to do some living activities themselves. such patients is impeded by the factors including careless
Insufficient nutrition is among the common problems displacement of feeding tubes, slowed gastric emptying
which may be suffered by the patients in neurosurgery and fasting medical interventions [8]. In the assessment
intensive care unit [9]. For the treatment of disease, a of nutrition, the assessment tools are used in order to
well-timed and sufficient nutritional support is crucial take nursing history, make physical diagnosis and general
and it is related with staying longer in the intensive observation and measure the energy requirement and
care unit [4]. Due to the reasons including sedation, body parts.
mechanical ventilation or reduced consciousness, majority
of neurosurgery intensive care patients are not able to
eat by mouth. As a form of nutritional support, enteral Nursing History
feeding is favoured for these patients [10]. Specially, it
has been demonstrated that early enteral feeding reduces Through nutritional assessment, the nutritional
the duration of stay in hospital, medical expenses and the condition of individuals is evaluated and their
ratios of infection of neurosurgery intensive care patients requirement for support and/or instruction is defined
[4,10]. and the nutrition disorders are identified. Firstly, all
As demonstrated by the new analyses, the mortality patients are subjected to screening in order to define the
and morbidity ratios of the patients who are severely ill need for additional inspection and following nutritional
are affected by nutritional support [3,4,11,12]. Among support [9].
the patients who are severely ill and get nutritional

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Physical Examination Diagnostic Tests

General observation; the significant data on nutritional With the help of biochemical data, a diagnosis
condition is collected by general observation. A person can be made, the required alterations of diet can be
who is sufficiently nourished seems to have a good health defined or the particular insufficiencies of nutrition
and normal vitals while his/her nails, hair and skin have can  be determined before appearance of clinical
a healthy appearance [16]. signs Haemoglobin, serum transferrin, haematocrit,
Anthropometric measurements; the measurements of prealbumin, serum albumin and total lymphocyte count
weight, height, waist and arm circumference are included are the laboratory data commonly used. Via a weekly
in the anthropometric measurements. The comparison assessment of laboratory tests and anthropometric
of weight and height with the findings is performed in measurements, it is required to monitor the patients
a table where the standard measurements are given as getting nutritional support with regard to their weight
classified by gender, age, body frame as well as Body and vital signs [16]. Moreover, it is highly crucial to
Mass Index (BMI) that is calculated by the values of control blood sugar of such patients. Through strict
weight and height. Waist measurements that constitute sugar control, hypo/hyperglycaemia episodes are avoided
a clinical measure of abdominal fat cells are made just in neurologic patients that suffer from traumatic brain
above the top of hip bones. With the purpose of getting injury, subarachnoid haemorrhage and intracranial
data on the muscle mass, mid-arm circumference of the haemorrhage [12].
upper arm is measured [16].
Calorie count; the predictive equations are generally
used by the nutritionists and intensivists in neuro Nutritional Status Evaluation Tools
intensive care units in order to predict the basal energy
consumption of patients and define target calorie for In order to calculate the risk of malnutrition, the
them [12,16]. The daily calorie intake and risk of factors such as the patients’ height (or ulna length as
malnutrition of patients are defined by the nutritional surrogate) and weight, acuteness of illness or serum
therapy in these units. However, it is sometimes possible albumin and history of late serious loss of weight are
that nutrition is disrupted due to gastrointestinal used by majority of these tools [12] (Table).
symptoms and the procedure that is used inside or
outside critical care unit [4,17].

Table. Malnutrition screening tools used in the intensive care unit population
Screening test History Clinical data
Subjective global assessment Weight change over 2 weeks–6 months Subcutaneous fat
Change in diet intake (amount and type) Muscle wasting
Gastrointestinal symptoms Oedema
Functional capacity (change in) Ascitis
Malnutrition universal screening tool Unplanned weight loss over 3–6 months Body mass index
Acute disease effect
Nutritional risk screening Acute weight loss in 3–6 months Body mass index
Reduced dietary intake in last week Severe illness
Mini nutrition assessment Food intake Body mass index
Weight loss Mobility
Tripathy S. Nutrition in the neurocritical care unit. J Neuroanaesthesiol Crit Care. 2015;2:88–96.

Nutritional Support decrease the negative nitrogen balance and replace

calorie and protein early. Oral nutritional supplements,
It is essential to provide neurosurgery patients with parenteral nutrition, food fortification and tube feeding
sufficient nutritional for their overall management are contained in the nutritional support as stated by
[18]. With the purpose of bettering the nutritional ESPEN (European Society of Parenteral and Enteral
management, several various feeding methods have been Nutrition Guidelines) [18,21].
tested [19,20]. Such management has two objectives to

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Food Fortification rate of morbidity is associated with the insertion of such

tubes [20,27].
With the help of food fortification, sufficient food The problems with swallowing that necessitate
intake can be provided and the nutritional insufficiency placement of EN tubes for a long time are likely to be
can be avoided. In order to improve the nutrient content seen in the neuro intensive care unit patients [28,29].
which naturally emerges, mineral and vitamin compounds The patients having the risk of dysphagia are required
are joined to foods. With a view to improving protein to be defined by the neuro ICU staff and they must be
and/or calorie intake, a drink in the form of milkshake provided with EN tube feeding [12]. The complications
is given between meals three or four times a day [22,23]. including diarrhoea, tube occlusion, electrolyte and fluid
It has been demonstrated that food fortification improves imbalance, vomiting, intestinal cramping, hyperglycaemia,
nutritional intake of the neurosurgical patients that often nausea and aspiration must be avoided and evaluated
do not eat up whole meal served on their plates [24]. as a matter of nursing responsibilities for the patients that
Since food fortification supplies based on such particular are provided with tube feedings. Although enteral feeding
patients’ requirements, it is considerably recommended. has mostly minor complications, they can be rather
That is because various reasons (like appetite loss) cause severe. Nonetheless, it is possible for nurses to decrease
such patients to have difficulty in handling an intake of the occurrence and acuteness of these complications by
sufficient food, as it has been suggested. Therefore, nurses means of assessing the nutritional needs and clinical
may demand food fortifications ordered by physicians condition of the patients, placing the feeding tube
[16,25]. cautiously, tracking the feeding course and choosing
and developing the formula [16,26,30].

Enteral Nutrition
Oral Nutritional Supplements
Nutrients are directly delivered into GI system in
enteral nutrition with avoiding the mouth. As an active Oral nutritional supplements (ONS) constitute a
therapy, enteral nutrition diminishes the organism’s significant part of nutritional therapy. Malnutrition can
metabolic reaction to stress and adapts the immune be treated and prevented effectively by means of
system well. Compared to parenteral nutrition, enteral management of ONS. All critical nutrients are combined
nutrition is less expensive and it is favoured mostly in a balanced way in these supplements distinguished
because it has less serious complications and creates by dense nutrients and considerable energy [31].
more favourable patient results including infections, Various systematic examinations and meta-analyses
and length of stay and hospital cost [16,20]. which were performed with varying atmospheres and
patients with different illnesses and status have
demonstrated that ONS creates such benefits as decrease
Tube feedings in the risk of infections, complications and mortality
and improvement of nutritional condition and cognition
Containing the commercial formulas that are as well as effective costs. With the purpose of bettering
nutritionally balanced, tube feedings involve a tube or sustaining the nutritional condition and improving
inserted straight into the stomach, jejunum or duodenum. the intake of nutrients and energy, it is recommended
By inserting a tube into intestine or stomach via nose by the ESPEN guidelines related to enteral nutrition to
or abdominal wall percutaneously, the GI system can use ONS for the undernourished patients or those having
be accessed [16,20,26]. The patients that have active GI the risk of undernutrition [16,31].
system but a problem with swallowing or an illness When it is deemed that there is serious malnutrition
promoting malnutrition are provided with nutrition by and/or nutrition intakes aren’t proper in spite of
tube feedings. Upon reduction of consciousness level, nutritional advices, it is suggested to use ONS. As it has
the tube feedings have been shown to hamper safe eating. been reported, the underdiagnoses of malnutrition are
For the neurosurgical patients that are able to eat but the leading restriction of this approach [32].
fail to satisfy the nutritional requirement of body by
sufficient nutrients, the tube feedings are applied as a
combined therapy. It is proper to use tube feedings on Parenteral Nutrition
the condition that it is possible to absorb the nutrients
from GI tract [16]. The use of these tubes for a long The patients that cannot digest nutrients from the
time might create different complications and troubles gastrointestinal tract are provided with carbohydrate,
influential on quality of life and lead to some outcomes electrolytes, protein, minerals, fat, vitamins and fluids
on the use of health care economically even if the lower supplied by parenteral nutrition. When it is shown that

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