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Energy Expenditure in Patients With Nontraumatic Intracranial Hemorrhage

Dema Halasa Esper, MS, RD, CNSD^*, William M. Coplin, MD^, and J. Ricardo Carhuapoma, MD, FAHA^,¶,||

From the ^* Department of Nutrition, Detroit Receiving Hospital, Detroit, Michigan; Department of Neurology and Department of Neurological Surgery, Wayne State University School of Medicine, Detroit, Michigan; and the Departments of Neurology,^¶ Neurological Surgery, and^|| Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland

Correspondence: J. Ricardo Carhuapoma, MD, FAHA, Division of Neurosciences Critical Care, The Johns Hopkins Hospital, 600 North Wolfe Street/Meyer 8-140, Baltimore, MD 21287. Electronic mail may be sent to jcarhua1{at}jhmi.edu.

Background: Patients with intracerebral (ICH), intraventricular (IVH) and subarachnoid hemorrhage (SAH) have increased morbidity and mortality compared with other forms of stroke. We postulate that the systemic inflammatory state triggered by these forms of nontraumatic intracranial hemorrhage (IH) translates into higher nutrition requirements than traditionally assumed. In order to test this hypothesis, we performed a retrospective study comparing the resting energy expenditure (REE) of 14 mechanically ventilated IH patients with the REE of 6 severe traumatic brain injury (sTBI) patients (a disease known to induce an increased metabolic state). Methods: Using nonparametric analysis, we compared 2 contemporary cohorts of patients—IH and sTBI—who required mechanical ventilation and who underwent indirect calorimetry (IC) within 7 days after the ictus. Results: Fourteen patients with nontraumatic IH (IVH, 2; SAH, 9; SAH/ICH, 1; ICH/SAH/IVH, 2) who underwent IC within 7 days from injury were identified; median age: 59 (28–84) years, median admission Glasgow Coma Scale (GCS): 6 (4–9), and median APACHE II: 19.5 (15–28). A control cohort of 6 patients with sTBI was identified; median age: 57.5 (18–80) years, admission GCS: 6.5 (4–8), and APACHE II: 16 (11–31). Sedation was used in 11/14 patients with IH and in 5/6 severe TBI patients. No patient was pharmacologically paralyzed. Median REE was 1810 (1124–2806) and 2238 (1860–2780) kcal/d for the IH and for the sTBI patient cohorts, respectively. Using Wilcoxon signed ranks test, the 2 patient groups were found comparable in regard to baseline clinical variables and disease severity (APACHE II). We did not identify a statistically significant difference in the REE between these 2 cohorts of patients (p = .25). Conclusions: Patients with severe TBI and patients with IH have similar increments in metabolic rate during the initial phase (1 week from onset) of their disease. This information needs to be confirmed in a larger cohort of patients. If reproduced, our results suggest that nontraumatic IH patients are at high risk of inadequate nutrition if their metabolic rate is estimated after conventional nutrition practice.

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