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KEY POINTS

KEY POINTS

  • Nutritional therapy should be integrated into the overall management of all trauma, surgery, and critically ill patients.

  • Nutritional needs and requirements are different in healthy patients compared to the critically ill and severely injured, hypermetabolic trauma patients.

  • Early enteral/oral feeding is a proactive therapeutic strategy that may reduce disease severity, decrease complications, and favorably impact outcomes.

  • Enteral/oral feeding is the preferred mode of nutrition for trauma, surgical, and critically ill patients.

  • Early parenteral nutrition should be considered if enteral feeds are contraindicated or are not expected to be started for 3 days.

  • Avoid long periods without enteral or parenteral nutrition..

  • Underfeeding during the stress-related catabolic phase or the immediate postoperative period is a risk factor for complications.

INTRODUCTION AND HISTORICAL PERSPECTIVE

Dietary choices impact disease. In the outpatient setting, dietary choices influence our risk for heart disease, cancers, obesity, diabetes, and stroke1,2; poor dietary choices increase the chance for developing these chronic and acute conditions, many of which are among the leading causes of morbidity and mortality in the United States and the world.3,4 Five of the 10 leading causes of death in the United States are directly associated with dietary factors (heart disease, cancer, stroke, diabetes, and atherosclerosis).5 In addition, dietary interventions can be a primary treatment for these conditions, with outcomes equivalent to or better than drug therapy.6

In the inpatient, hospital-based setting, a patient’s nutritional status also impacts clinical outcomes. This notion was first reported in surgical patients in the year 1936, in a study demonstrating that patients with baseline malnutrition undergoing peptic ulcer surgery had mortality rates of 33% compared to 3.5% in well-nourished controls.7 This pattern has been reported repeatedly since then, with preoperative malnutrition leading to increased morbidity and mortality in the surgical and trauma literature. With the prevalence of baseline malnutrition among hospitalized medical and surgical patients as high as 40%,8,9 many patients are at high risk for poor outcomes and complications.

Anticipating and addressing hospitalized patients’ dietary needs can therefore substantially impact their disease as well as their outcome. Simply put, providing adequate nutrition is essential to high-quality patient care, and given the extreme physiologic, metabolic, and homeostatic changes that can occur after severe injury, nowhere in medicine is this more true than in trauma, surgery, and critical care.

This chapter is about nutrition, the inflammatory stress responses to injury, and the nutritional needs of the polytrauma patient, for both macro- and micronutrients. The first major section on nutritional support provides a thorough, up-to-date guide on nutrition: first, nutritional needs and requirements are addressed in both the healthy patient and the critically ill, hypermetabolic trauma patient; second, we outline the specifics of nutritional intervention, including both enteral and parenteral nutritional support; and last, we cover some special patient populations. The second major ...

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