Clinical malnutrition in severe traumatic brain injury : Factors associated and outcome at 6 months

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Original Article
Indian Journal of Neurotrauma (IJNT)
2007, Vol. 4, No. 1, pp. 35-39
Clinical malnutrition in severe traumatic brain injury:
Factors associated and outcome at 6 months
SS Dhandapani M Ch, D Manju M Sc*, BS Sharma M Ch, AK Mahapatra M Ch
Departments of Neurosurgery and Neuronursing*
AIIMS, New Delhi.
Abstract: Traumatic brain injury increases the metabolic response of body, and therefore nutritional
demands. This study was undertaken to evaluate various clinical features of malnutrition in TBI and
their influence on neurological outcome. Eighty eight adult patients within 24 hours of TBI admitted
with GCS 4 to 8 without serious systemic disorder were enrolled for the study. They were monitored
serially for various clinical features of malnutrition till 3 weeks and outcome assessed at 6 months.
Every week there was a significant increase in number of patients with various clinical features of
malnutrition. Pedal edema was the most frequent sign present in 70% of patients at three weeks,
followed by skeletal prominence (19%) and cheilosis (12%). Clinical malnutrition showed significant
association with poorer GCS (p=0.03), admission hypoproteinemia (p=0.03), and delayed full enteral
feeding (p<0.001). Unfavorable outcome at 6 months was noted in 30 out of 37 patients who had
clinical malnutrition as compared to 3 out of 15 patients who had no clinical features of malnutrition
(odds ratio 17.2, p<0.001). In multivariate analysis, clinical malnutrition was significantly associated
with unfavorable outcome independent of GCS (p=0.002). Analysis of individual clinical markers
revealed pedal edema as the only single clinical marker with significant influence on unfavorable
outcome at 6 months (p=0.01). Clinical malnutrition developed more among patients with poorer
GCS, admission hypoproteinemia, delayed full enteral feeding, and was associated with unfavorable
outcome at 6 months. Among the various clinical markers, only pedal edema showed independent
association with unfavorable outcome.
Keywords: Brain injury, clinical features, malnutrition, outcome
INTRODUCTION
for 1 week, under the Department of Neurosurgery,
AIIMS, New Delhi, from June to December 2005, were
Traumatic brain injury (TBI) is a major cause of disability,
enrolled for the study. Patients with age more than 60
death and economic cost to our society1,2. The increased
years, GCS 3, those with any significant systemic disorder
energy expenditure and nitrogen excretion following
or patients who expired within 1 week had been excluded.
severe TBI mandates adequate nutritional support to
provide the optimal milieu for neurological and systemic
Standard care given to study patients consisted of
recovery3,4,5. Despite the growing importance of
ventilation, seizure prophylaxis with phenytoin,
nutritional support in patients with severe TBI, the
antibitiotic prophylaxis with cefotaxime or ceftriaxone
clinical features suggestive of malnutrition has not been
and netilmycin, and gastric ulcer prophylaxis with
adequately studied in relation to other factors and
ranitidine. Mannitol was given to patients with computed
neurological outcome. This was a prospective study to
tomography (CT) having evidence of mass effect.
evaluate various clinical markers of malnutrition in
Frusemide was added to patients with midline shift. Fluid
and electrolyte homeostasis was maintained. Decision
patients with severe TBI, factors associated and their
regarding surgical decompression was taken according
influence on outcome at 6 months.
to the mass effect noted in CT and was individualized to
MATERIALS AND METHODS
each patient. Enteral feeding was initiated either through
nasogastric tube or orally as early as possible and the
Adult patients within 24 hours of TBI admitted with
volume of feed increased gradually according to the
Glasgow coma scale (GCS)6 4 to 8, hospitalized at least
gastric tolerance. Patient characteristics, post-
resuscitation admission GCS, biochemical parameters
Address for correspondence:
at admission and serial monitoring for various clinical
features of malnutrition till 21 days were noted down in
Dr SS Dhandapani M Ch
Dept of Neurosurgery, AIIMS, Ansari Nagar
a pre-planned prospective database and were followed
New Delhi - 110029
up.
Indian Journal of Neurotrauma (IJNT), Vol. 4, No. 1, 2007

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36
SS Dhandapani, D Manju, BS Sharma, AK Mahapatra
Serum albumin and total protein levels at admission
were tested by Bromcresol green dye binding method
and Biuret method respectively using Beckman Synchron
CX5 Delta Clinical System (GMI Inc, Minnesota) 7. An
observational check list to assess the clinical features of
malnutrition8,9,10 was developed with the following five
clinical markers: pedal edema, cheilosis, skeletal
prominence, xerosis and gingival bleeding. The inter rater
reliability of observational check list on trial 10 patients,
obtained between two investigators was more than 90%
(100% among four parameters).
Fig 1: Prevalence of clinical malnutrition
Outcome
The primary outcome was Glasgow outcome scale (GOS)
11 assessed at 3 and 6 months following injury either
directly or over telephone. Good recovery or moderate
disability was considered as favorable outcome and severe
disability, persistent vegetative state or death was
considered as unfavorable outcome.
Statistical analysis
SPSS software (version 10, SPSS Inc, Chicago) was used
for the statistical analyses. Continuous variables in two
groups were compared by using independent-samples T
test. Proportions were compared by using chi-square
tests or Fisher’s exact test, wherever appropriate.
Fig 2: Clinical markers of malnutrition
Multivariate analysis was conducted with logistic
features of malnutrition (37 Vs 32 years) did not show
regression adjusting for age, admission GCS, systemic
significant difference (P=0.07). Also there was no
injury, surgical intervention, and presence of clinical
significant gender difference (P=0.09). However the
features of malnutrition. Two sided significance tests were
clinical features showed significant association with
used throughout, and the significance level was kept at
poorer admission GCS (P=0.03), as shown (Fig 3).
P < 0.05.
RESULTS
From June to December 2005, 88 patients in the age
group 18-60, that fulfilled the eligibility criteria were
enrolled for the study. The mean age of study sample
was 35.4. There were 81 males and 7 females. Every
week there was a significant increase in number of
patients with various clinical features of malnutrition
(Fig 1). 76% of patients presented with clinical features
Fig 3: GCS Vs Clinical features
of malnutrition at three weeks.
Pedal edema was the most frequent sign present in
Hypoproteinemia (serum total protein < 5.5 g/dL) at
70% of patients at three weeks, followed by skeletal
admission showed significant association with
prominence (19%) and cheilosis (12%). The distribution
development of clinical features of malnutrition with odds
based on clinical features at weekly intervals is as shown
ratio (OR) 7.5 (95% CI 0.9- 58.8) and P value 0.03 (Fig
(Fig 2).
4). The mean admission serum albumin level in patients
who developed clinical features of malnutrition was 3.16
The mean age of patients with or without clinical
(+SD 0.5) g/dL, as compared to 3.39 (+SD 0.4) g/dL
Indian Journal of Neurotrauma (IJNT), Vol. 4, No. 1, 2007

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Clinical malnutrition in severe traumatic brain injury: Factors associated and outcome at 6 months
37
Among the individual clinical markers, pedal edema and
cheilosis were significantly associated with unfavorable
outcome at 6 months (OR P < 0.001 and P = 0.02,
respectively). The presence of skeletal prominence
showed significant association with unfavorable outcome
at 3 months (P=0.002), but insignificant at 6 months
(P=0.07).
Fig 4: Serum total protein Vs Clinical features
among those who did not develop clinical features. The
difference was statistically significant (P=0.046).
Full enteral feeding later than 7 days after admission
showed significant association with development of
clinical malnutrition (94%) as compared to early enteral
feeding (54%) with OR 13 (95% CI 2.8-59.7) and P <
Fig 6: Clinical malnutrition Vs Outcome at 6 months
0.001 (Fig 5). Associated systemic injury, computed
tomography findings, surgical intervention and prolonged
There was significant association of clinical
ventilation showed insignificant association with
malnutrition with mortality (40%) as compared to
development of clinical malnutrition.
patients who had no clinical features of malnutrition
(11%). The OR was 5.6 (95% CI 1.5-20.4) and P value
0.006 (Fig 7).
Fig 5: Timing of full enteral feeding Vs Clinical features
Neurological outcome and mortality
Fig 7: Clinical malnutrition Vs Mortality
Neurological outcome at 3 and 6 months was assessed
Multivariate analysis
in 68 and 52 patients respectively. Unfavorable outcome
at 6 months was noted in 30 out of 37 patients who had
Logistic regression analysis was performed on
clinical malnutrition as compared to 3 out of 15 patients
neurological outcome adjusting for the influence of age,
who had no clinical features of malnutrition. The OR
GCS, associated systemic injury and surgical
was 17.2 (95% CI 3.8-76.9) and P < 0.001 (Fig 6).
intervention. The presence of clinical malnutrition was
Indian Journal of Neurotrauma (IJNT), Vol. 4, No. 1, 2007

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38
SS Dhandapani, D Manju, BS Sharma, AK Mahapatra
significantly associated with unfavorable outcome at 6
followed by cheilosis. These may act as valuable markers
months with adjusted OR 12.5 (95% CI 2.6-61) and P
of the adequacy of nutritional replacement in future
value 0.002. Among the individual clinical markers, only
studies. In conclusion, clinical assessment is efficient in
pedal edema emerged in multivariate analysis to be
identifying patients with malnutrition with significant
significantly associated with unfavorable outcome at 6
impact on outcome at 6 months.
months (adj. OR 8.4, P=0.01).
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