Practice management guidelines for nutritional support of the trauma patient.

Nutritional support is an integral, though often neglected, component of the care of the critically injured patient. Our understanding of the metabolic changes associated with starvation, stress, and sepsis has deepened over the past 20 to 30 years, and along with this has come a greater appreciation for the importance of the timing, composition, and route of administration of nutritional support to the trauma patient. Although supportive data exist for many of our current nutritional practices, the trauma surgeon cannot assume that interventions that are successful in laboratory animals or even in the critically ill nontrauma patient will produce the same results in critically ill trauma patients. Stanley J. Dudrick, MD, one of the forefathers of surgical nutrition in this country, put it this way: “. . .we do get ourselves into an awful lot of trouble and lack of consensus as a result of mixing in animal data together with normal, starved man data when we are talking about trauma, especially in burns.” For this reason, the recommendations provided in this guideline are based, when at all possible, on studies using trauma or burn patients. Nevertheless, a brief discussion of some of the basic science principles of nutritional support is provided in the following section as a backdrop for the clinical studies presented in this guideline. This practice management guideline is a compilation of six separate guidelines; each addresses a specific aspect of the nutritional support of the trauma patient. These topics are presented in the following order: A. Route of nutritional support (total parenteral nutrition vs. total enteral nutrition). B. Timing of nutritional support (early vs. late). C. Site of nutritional support (gastric vs. jejunal). D. Macronutrient formulation (how many calories and what proportion of protein, carbohydrate, and fat?). E. Monitoring of nutritional support (which tests and how often?). F. Type of nutritional support (standard vs. enhanced). Each subguideline is a separate and free-standing document, with its own recommendations, evidentiary tables, and references. Where possible, we have attempted to eliminate redundancy and ensure consistency among the guidelines. Yet, because of substantial differences in both the quantity as well as the quality of supporting scientific data for each topic, and the fact that certain clinical circumstances are not conducive to a single guideline, concise and consistent recommendations were not always possible. Even when Class I (prospective, randomized, controlled) studies were available, limited patient numbers and inconsistent definitions rendered study conclusions less authoritative that they might have otherwise been. Recognizing the need to incorporate the major recommendations from the subguidelines into a logical overall approach to the nutritional support of the trauma patient, a summary algorithm is provided at the conclusion of the guideline (Fig. 1). Because of the scope of this document, many of the recommendations from the subguidelines could not be included in the algorithm. In addition, distinguishing between the various levels of recommendations (I, II, and III) within the algorithm was not practical. Nevertheless, the algorithm provides a safe, reasonable, and literature-supported approach to nutritional support and, we hope, will provoke constructive discussion and stimulate further investigation.