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Energy Expenditure in Children After Severe Traumatic Brain Injury

Mtaweh, Haifa MD1,2; Smith, Rebecca MD1,2; Kochanek, Patrick M. MD1,2; Wisniewski, Stephen R. PhD3; Fabio, Anthony PhD3; Vavilala, Monica S. MD4; Adelson, P. David MD5; Toney, Nicole A. MPH1,2; Bell, Michael J. MD1,2,6

Pediatric Critical Care Medicine:
doi: 10.1097/PCC.0000000000000041
Neurocritical Care
Abstract

Objective: To evaluate energy expenditure in a cohort of children with severe traumatic brain injury.

Design: A prospective observational study.

Setting: A pediatric neurotrauma center within a tertiary care institution.

Patients: Mechanically ventilated children admitted with severe traumatic brain injury (Glasgow Coma Scale < 9) with a weight more than 10 kg were eligible for study. A subset of children was co-enrolled in a phase 3 study of early therapeutic hypothermia. All children were treated with a comprehensive neurotrauma protocol that included sedation, neuromuscular blockade, temperature control, antiseizure prophylaxis, and a tiered-based system for treating intracranial hypertension.

Interventions: Within the first week after injury, indirect calorimetry measurements were performed daily when the patient’s condition permitted.

Measurements and Main Results: Data from 13 children were analyzed (with a total of 32 assessments). Measured energy expenditure obtained from indirect calorimetry was compared with predicted resting energy expenditure calculated from Harris-Benedict equation. Overall, measured energy expenditure/predicted resting energy expenditure averaged 70.2% ± 3.8%. Seven measurements obtained while children were hypothermic did not differ from normothermic values (75% ± 4.5% vs 68.9% ± 4.7%, respectively, p = 0.273). Furthermore, children with favorable neurologic outcome at 6 months did not differ from children with unfavorable outcome (76.4% ± 6% vs 64.7% ± 4.7% for the unfavorable outcome, p = 0.13).

Conclusions: Contrary to previous work from several decades ago that suggested severe pediatric traumatic brain injury is associated with a hypermetabolic response (measured energy expenditure/predicted resting energy expenditure > 110%), our data suggest that contemporary neurocritical care practices may blunt such a response. Understanding the metabolic requirements of children with severe traumatic brain injury is the first step in development of rational nutritional support goals that might lead to improvements in outcome.

Author Information

1Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA.

2Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA.

3Department of Epidemiology, University of Pittsburgh, Pittsburgh, PA.

4Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA.

5Barrow Neurological Institute at Phoenix Children’s Hospital, Phoenix, AZ.

6Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA.

Drs. Mtaweh and Smith contributed equally to the completion of the project.

Dr. Bell received support for article research from the National Institutes of Health. His institution received grant support from NIH. Dr. Smith received support for travel from the University of Pittsburgh Medical Center and Safar Center for Resuscitation Research, is employed as PICU fellow and attending at the University of Pittsburgh Medical Center, and received support for article research from NIH. Her institution received grant support from NIH (T32 Grant). Dr. Kochanek disclosed United States provisional patents (Method of Inducing EPR Following Cardiopulmonary Arrest 6/22/05, CMU Invention Disclosure 2012-081: Validation of a Multiplex Biomarker Panel for Detection of Abusive Head Trauma in Well-Appearing Children 1/10/2012, and United States Invention Disclosure: Small Molecule Inhibitors of RNA Binding MOTIF (RBM) Proteins for the Treatment of Acute Cellular Injury). He received support for article research from NIH. His institution received grant support from NIH (NS070003), US Army, DARPA, Laerdal Foundation, and AHA (Dr. Kochanek has numerous grants under consideration from these entities, including grants for trainees). Dr. Wisniewski‘s institution received grant support from NIH. Dr. Adelson receives royalties from Thieme Publishing and consulted for Tramatec. His institution received grant support from NIH, Integra Life Sciences, and Codman. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: bellmj4@upmc.edu

©2014The Society of Critical Care Medicine and the World Federation of Pediatric Intensive and Critical Care Societies