"Cool" Topic: Feeding During Moderate Hypothermia After Intracranial Hemorrhage

Therapeutic moderate hypothermia (MH; T _core 33°C-34°C) is being studied for treatment of spontaneous intracerebral hemorrhage (ICH). Nutrition assessment begins with accurate basal metabolic rate (BMR) determination. Although early enteral nutrition (EN) is associated with improved outcomes, it is often deferred until rewarming. We sought to determine the accuracy of predictive BMR equations and the safety and tolerance of EN during MH after ICH.

Patients were randomized to 72 hours of MH or normothermia (NT; T _core 36°C-37°C). Harris-Benedict (BMR-HB) and Penn-State equation (BMR-PS) calculations were compared with indirect calorimetry (IC) at day (D) 0 and D1-3. Patients with MH received trophic semi-elemental gastric EN. Occurrences of feeding intolerance, gastrointestinal (GI)-related adverse events, and ventilator-associated pneumonia (VAP) were analyzed with a double-sided matched pairs t test.

Thirteen patients with ICH participated (6 MH, 7 NT). Mean time to initiate EN: 29.9 (MH) vs 18.4 (NT) hours ( P = .046). Average daily EN calories received D0-3: 398 (MH) vs 1006 (NT) ( P < .01). Three patients with MH experienced high gastric residuals prior to prokinetic agents, 1 had mild ileus, and 1 patient with NT vomited. No GI-related adverse events were reported. One patient with MH and 1 patient with NT had VAP. Two patients with MH received IC, and from D0 to D1-3, BMR-HB remained stable (1331 kcal), BMR-PS decreased (1511 vs 1145 kcal, P = .5), and IC decreased (1413 vs 985 kcal, P = .2).

In patients with ICH undergoing MH, resting energy expenditure is decreased and predictive equations overestimate BMR. EN is feasible, although delayed EN initiation, high gastric residuals, and less EN provision are common. Future studies should focus on EN initiation within 24 hours, advanced EN rates, and postpyloric feeds during hypothermia.