LONG-TERM NUTRITIONALCONSIDERATIONS AFTER SPINAL CORDINJURY AND/OR TRAUMATIC BRAININJURY

Angela Luciani, RD, LDNMagee Rehabilitation HospitalPhiladelphia, PA

SPEAKER DISCLOSURE STATEMENT

Angela Luciani is a Registered Dietitian with Magee Rehabilitation Hospital

No off-label use will be discussed Angela Luciani has no industry relationships to

disclose

OBJECTIVES

1. Describe nutritional considerations for best practice in SCI/TBI patients at high risk for skin breakdown

2. Explain how changes in body composition can impact health status after SCI

3. Discuss case studies which illustrate the typical nutritional needs/interventions provided by Magee’s RD for outpatients with chronic SCI

NUTRITION MATTERS

• Malnutrition is associated with:– A 200–500% higher risk for

Pressure Ulcers among other conditions,

– Significant increased risk for falls

– 2-3 times increased risk for developing surgical-site infection or postoperative pneumonia

• Patients who develop HACs are – 60% more likely to be in an

ICU, – Have increased nutritional

needs & higher risk of malnutrition and subsequent increase in HACs

Inflammatory Response to

Illness, Surgery, Trauma

Malnutrition

Hospital Acquired

Conditions (HACs)

A.S.P.E.N CLINICAL CHARACTERISTICS TOIDENTIFY AND DOCUMENT MALNUTRITION

Presence of 2 out of the following 6 characteristics are used to diagnose malnutrition Decreased oral intake Weight loss Fat loss Muscle wasting Fluid accumulation Decreased grip strength

Consensus statement: Academy of nutrition and dietetics and American society for parenteral and enteral nutrition: Characteristics recommended for the identification and documentation of adult malnutrition (undernutrition) White J.V., Guenter P., Jensen G., Malone A., Schofield M. (2012) Journal of Parenteral and Enteral Nutrition, 36 (3) , pp. 275-283.

6

Acute with Chronic stress response, hyperglycemia w/increased inflammatory

cytokines

Altered nutrient utilization & loss of LBM, gastroparesis,

vascular complications, infection risk

Delayed wound healing, poor response to standard interventions, need for BG

& GI monitoring, & education

Obesity, Diabetes,Organ compromise,

Multiple co-morbidities

Acute illness & MalnutritionMaking the Connection

Acute Hospitalization

NUTRITION STATUS AFTER SEVERE TBI ORSCI 40-50% of patients admitted to hospitals are at

risk of nutritional deficiency with 12% severely malnourished

TBI 68% of TBI patients are malnourished Weight loss 10-29% - occurs within the first and

second month SCI

Persons with SCI variable prevalence of obesity from 40 to 66%

J Clin Med Res. 2012 Aug; 4(4): 227–236. Published online 2012 Jul 20. doi: 10.4021/jocmr924wKrakau, K., A. Hansson, T. Karlsson, C.N. de Boussard, C. Tengvar, and J. Borg, Nutritional treatment of patients with severe traumatic brain injury during the first six months after injury. Nutrition, 2007. 23(4): p. 308-17.

NUTRITIONAL PROBLEMS AND RELATEDHEALTH ISSUES

Spinal Cord Injury Traumatic Brain Injury- GI issues - Muscle atrophy with increased

muscle spasms untilmedicated

- Altered metabolic and nutritional deficiencies

- Loss of LBM- Unwanted weight gain- Risk of obesity, metabolic

syndrome, heart disease

- GI issues - Increased muscular activity - Increased energy

requirements - Loss of LBM - Cognitive Deficits - Obesity, metabolic syndrome,

heart disease

PROTEIN NEEDS AND CRITICAL ILLNESS –IMPROVING OUTCOMES

Review of the current evidence: Protein supplementation has the potential to improve

the recovery of critically ill patients Experts now recommend 2.0-2.5g PRO/kg/d in critical

illness Most critically ill patients receive only .6g/kg/d International studies report protein malnutrition

rates in the acute care setting of approximately 40%

NUTRITION ASSESSMENT

Team communication with nursing liaison before patient arrives

Screening of high risk patients within 24 hours Malnutrition assessment performed by an RD Collaboration with Wound Care team Ensuring adequate protein by day 2 of admission

TEAM APPROACH TO ASSESSMENT

Clinical Nutrition is under the Department of Nursing, separate from the Department

of Food Service

RD screens within 24-48 hours upon

admission to Magee Rehab with a WOCN –

team approach

Anthropometrics

“PIAG” (bowel rounds using Bristol Stool Chart)

Co-treat with SLP On-sight video swallow studies

Specialty supplements and products for

dysphagia

Adjust diet to the patient – not force

patient to fit the diet

Experience based strategies to increase

intake

BARRIERS TO ADEQUATE NUTRITION

Age Skin breakdown Dependent for feeding Adjustment to disability Malnutrition

I CAN SWALLOW BUT CAN I EAT?

TRANSITION THROUGH REHAB TOOUTPATIENT

Tube feeding recommendations and speech therapy

Coordinating with case managers and collaboration with team for discharge recommendations

Free care supplements to bridge from inpatient to outpatient for transitioning home

Nutrition education classes Referrals to dietitian in outpatient setting

LONG-TERM NUTRITION CONSIDERATIONSIN SCI / TBI Increased risk for cardiovascular disease due to

inactivity and immobilization (metabolic syndrome)

Changes in weight Calorie, protein, fluid needs Education

FOLLOW-UP

Magee’s lifetime follow-up Weight Tube feeding management Dietary recommendations

Supplements PEG placement Referrals to community services for food security

CASE STUDY #1 – TOO FATIGUED TO MEETINCREASED METABOLIC NEEDS

21 YO AA M presents with C4 Incomplete Quad w/ Trach

No PMHDOO:Admission to MRH:

9/1218 days later

Anthropometrics: BMI: 19.9% wt loss: 16%

Skin issues on admit: No

Diet Transfer: Ground and thins4 days prior to transfer: Cleared for P.O. diet and NG tube removed

IV fluids on admit: No

RD assessment: Pt with inadequate PO intake, increased calorie and protein needs

NUTRITIONAL CONCERNS ANDINTERVENTIONS

Acute•Passed swallow

study•Skin intact per

transfer •NG tube removed.

Rehab•Rehab-SLP agrees with transfer diet recommendations

•CWOCN – skin breakdown noted on admit•RD – inadequate intake, >1 hour to consume <25% of meals

Intervention during Rehab• PEG placement• Various modulars to

meet special needs • Nutrition education

classes

Discharge plans• Discharged with PEG in place• Education regarding weight and

smart eating choices• PEG care

CASE STUDY #2 – DELAYED PEG PLACEMENTWITH HYPERMETABOLIC NEEDS

58 YO W M presents with C5 Tetra (Vent/Trach/PEG)

No PMH prior to injuryDOO:Admission to MRH:

10/1518 days later

Anthropometrics: BMI: 21.4% wt loss: 3.7%

Skin issues on admit: Sacral UnstageableDiet Transfer: NPO

PEG placed: 10/23 (9 days after onset of injury) IV fluids on admit: NoRD assessment: Dry oral cavity, loss of LBM, loss of fat mass

NUTRITIONAL CONCERNS ANDINTERVENTIONS

Acute• Delayed PEG

placement• High calorie

and protein needs

Rehab• Unstageable sacral

on admit• Multiple issues

with enteral nutrition administration

• Above average / recommended calorie needs

Intervention• Providing above

“estimated needs”• Clinical judgment

and collaboration with wound care

Discharge• Enteral

nutrition insurance coverage

• Communicating with case manager and vendors regarding supplies

CASE STUDY #3 – INCREASED PROTEIN AND CALORIE NEEDS WITH NG REMOVED PRIOR TO REHAB

57 YO W M presents with T2-T6 Fx Tetra (Vent/Trach/PEG)

No PMH prior to injuryDOO:Admission to MRH:

8/2230 days later

Anthropometrics:

BMI: 31% wt loss: 7.5%

Skin issues on admit:

Surgical incisions

Diet Transfer: Nectars and PureeDobhoff Tube in acute – pulled before admission

IV fluids on admit:

No

RD assessment: Dry oral cavity, loss of LBM, loss of fat mass

NUTRITIONAL CONCERNS ANDINTERVENTIONS

Acute• DHT in place• Communication

with nursing liaison

• High calorie and protein needs

Rehab• Admitted without

DHT • Seen by SLP, VFSS

completed, upgraded to regular

Intervention• Provided protein

modulars, snacks and calorie-dense supplements for meeting estimated needs

• Clinical judgment and collaboration with speech therapy

Discharge• Education regarding

healthy weight and skin integrity

CASE STUDY #4 – HIGH CALORIE AND PROTEINNEEDS; PT REQUESTING PEG REMOVAL

69 YO W F presents with TBI:VDRF (Trach/PEG)Noncontributory PMH

DOO:Admission to MRH:

7/2210 days later

Anthropometrics: BMI: 27.22% wt loss: n/a, masked by edema

Skin issues on admit: Stage 1 at PEG site

Diet Transfer: NPO, receiving enteral nutrition via PEG tube

IV fluids on admit: NoRD assessment: Dry oral cavity, loss of LBM, loss of fat mass;

Claviclular and scapular wasting.

NUTRITIONAL CONCERNS ANDINTERVENTIONS

Acute•PEG placement•High calorie and protein needs sec to TBI

Rehab•Admitted on NPO diet, PEG in place

•Seen by SLP•Modulars enteral nutrition administration

•Pt with small appetite

•Wt loss

Intervention•Calorie counts•Education on recommended needs

•Structure at meal times and frequent snacks

Discharge• Discharge with PEG in place

•Ensure adequate nutrition –consistent before PEG removal

SUMMARY

Nutrition interventions and on-going education are important at each stage of recovery

Rehab setting can be difficult for managing diet and weight; requires “buy-in” from patient and family

Becoming aware of long-term nutrition-related complications in SCI and TBI may help address issues early on and achieve better outcomes

QUESTIONS?

REFERENCES

J Clin Med Res. 2012 Aug; 4(4): 227–236. Published online 2012 Jul 20. doi: 10.4021/jocmr924w

Consensus statement: Academy of nutrition and dietetics and American society for parenteral and enteral nutrition: Characteristics recommended for the identification and documentation of adult malnutrition (undernutrition) White J.V., Guenter P., Jensen G., Malone A., Schofield M. (2012) Journal of Parenteral and Enteral Nutrition, 36 (3) , pp. 275-283.

Krakau, K., A. Hansson, T. Karlsson, C.N. de Boussard, C. Tengvar, and J. Borg, Nutritional treatment of patients with severe traumatic brain injury during the first six months after injury. Nutrition, 2007. 23(4): p. 308-17.