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

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.