A multidisciplinary nutrition-support approach in severe polytrauma: A case report

Malarkodi M*

Department of Clinical Nutrition and Dietetics, Kauvery Hospital, Radial Road, Chennai, Tamil Nadu

*Correspondence

Abstract

Severe polytrauma is associated with a substantial metabolic and nutritional burden. Repeated surgeries, sepsis, respiratory complications, gastrointestinal injury, prolonged immobilisation, and feeding interruptions can significantly affect nutritional adequacy and recovery. This case report describes the nutritional management of a young adult male with extensive multisystem trauma who required prolonged critical care, multiple surgical procedures, and rehabilitation.

The nutrition-support plan was progressively adapted from nil per oral status and parenteral nutrition to enteral feeding, oral nutrition supplements, and a soft-solid diet. Serial nutritional assessments and monitoring of energy and protein intake guided the transition between feeding routes. By discharge, the patient was tolerating oral intake, had adequate nutritional intake, and was mobilising with assistance. This case highlights the importance of individualised, multidisciplinary nutrition care throughout the continuum of critical illness and rehabilitation.

Keywords: Polytrauma, Nutrition support, Enteral nutrition, Parenteral nutrition, Oral nutrition, Wound healing, Critical care, Clinical dietetics.

Introduction

Polytrauma produces a complex physiological response characterised by inflammation, increased metabolic demand, tissue injury, and impaired functional capacity. Nutritional management may be challenging when the patient has abdominal trauma, sepsis, respiratory failure, repeated operative procedures, gastrointestinal intolerance, and prolonged periods of fasting. Early nutritional assessment and regular adjustment of nutrition support are important components of comprehensive trauma care. This report describes the clinical nutrition management of a patient with severe polytrauma during a prolonged hospital admission, with emphasis on the transition from parenteral nutrition to enteral and oral feeding.

Case Presentation

A 30-year-old man was admitted following a high-impact road-traffic accident involving a two-wheeler and a bus. He sustained severe injuries to the head, chest, abdomen, upper limbs, and lower limbs and initially required intubation, fluid resuscitation, and blood-component therapy at a nearby healthcare facility. On admission to the tertiary-care hospital, he was haemodynamically unstable, with tachycardia and hypotension. The initial evaluation identified traumatic brain injury with subarachnoid haemorrhage, thoracic spine injury, manubrial fracture, bilateral lung contusions, aspiration pneumonia, acute respiratory distress syndrome, bowel perforation with haemoperitoneum and pneumoperitoneum, abdominal-wall injury, multiple limb fractures, soft-tissue injury, sepsis with septic shock, and acute kidney injury. Emergency exploratory laparotomy was performed during the initial phase of treatment. During the hospital course, the patient required repeated wound exploration and debridement, management of abdominal and retroperitoneal collections, orthopaedic procedures, skin grafting, and spinal stabilisation. The prolonged inflammatory state, repeated procedures, wound complications, infection, and restricted mobility increased his nutritional requirements and risk of nutritional deterioration.

Nutritional Assessment

The initial nutritional assessment documented a height of 170 cm, weight of 70 kg, body mass index of 23.6 kg/m², and ideal body weight of approximately 72 kg. Modified Subjective Global Assessment indicated moderate nutritional compromise. Nutritional status was reviewed serially during the admission, with additional consideration of clinical condition, feeding tolerance, gastrointestinal symptoms, operative interruptions, and intake adequacy. The estimated nutritional prescription was approximately 2,000 kcal and 100 g protein per day. These targets were used as a guide and were adjusted according to clinical status and the patient’s ability to tolerate and absorb nutrition.

Nutrition Intervention

Initial phase: The patient was kept nil per oral during the early unstable and postoperative period. Parenteral nutrition was initiated and gradually advanced. This approach provided nutritional support while oral intake was contraindicated and enteral feeding was being assessed.

Transition to enteral nutrition: As the patient’s gastrointestinal condition and clinical stability permitted, nasogastric feeding was introduced. Enteral nutrition was progressively advanced using high-protein formula feeds. Parenteral nutrition was subsequently discontinued once enteral delivery became adequate.

Feeding was monitored daily, with adjustments made for procedures, feed interruptions, gastrointestinal symptoms, and changes in clinical requirements. During the enteral-feeding phase, the patient experienced episodes of loose stools and constipation, requiring review of feed composition, administration pattern, oral intake, fibre provision, and supportive management.

Transition to oral nutrition: A gradual oral-feeding trial was initiated with high-protein foods, including soft and easily tolerated preparations. Oral intake was advanced from clear liquids to a high-protein soft-solid diet. Oral nutrition supplements were used to improve energy and protein delivery when oral intake alone was insufficient.

At times, enteral feeding was temporarily reintroduced or modified when oral intake declined or clinical circumstances changed. Later in the admission, nocturnal nasogastric feeding was used to supplement daytime oral intake. This allowed the patient to increase oral intake gradually while continuing to receive additional nutritional support.

During the final phase, oral intake improved progressively. The nasogastric tube was removed after the patient demonstrated adequate oral intake, and he continued on a soft-solid diet with oral nutrition supplementation. The documented intake near discharge was approximately 2,159-2,230 kcal and 70-85 g protein per day

Clinical Outcome

Following prolonged multidisciplinary management, the patient became haemodynamically stable and was considered suitable for discharge with continued assisted care and rehabilitation at home. At discharge, he was conscious, oriented, awake, and able to communicate. He was breathing room air with a tracheostomy tube, receiving daily respiratory therapy, mobilising with a walker, and tolerating adequate oral nutrition.

Discussion

This case illustrates the changing nutritional requirements of a patient with severe multisystem trauma. A normal body mass index at admission did not exclude the risk of nutritional deterioration. The subsequent clinical course involved prolonged inflammation, sepsis, repeated surgical procedures, wound complications, respiratory compromise, and interruptions to feeding for all of which increased the importance of regular nutritional reassessment. The nutrition-support strategy evolved according to the patient’s clinical condition. Parenteral nutrition was used when oral and enteral routes were not initially feasible. Enteral nutrition was introduced and advanced when gastrointestinal feeding became possible. Oral intake was then developed gradually, supported by oral nutrition supplements and nocturnal enteral feeding when required.

A major feature of this case was the need for ongoing adjustment rather than reliance on a single nutrition prescription. Energy and protein delivery fluctuated in response to operative procedures, gastrointestinal tolerance, diarrhoea, constipation, and changes in oral acceptance. Monitoring actual intake enabled the nutrition team to identify periods of inadequate delivery and modify the feeding plan accordingly. The case also demonstrates the importance of integrating nutrition care with the wider multidisciplinary treatment plan. Surgical management, wound care, infection control, respiratory therapy, nursing care, physiotherapy, and rehabilitation all influenced nutritional needs and feeding tolerance. Adequate nutrition was therefore considered a component of functional recovery rather than an isolated supportive intervention.

Conclusion

Individualised nutrition support contributed to the nutritional management of a patient with prolonged critical illness and severe polytrauma. The stepwise progression from parenteral nutrition to enteral feeding, oral nutrition supplements, soft-solid meals, and eventual independent oral intake was guided by repeated assessment and clinical tolerance. This case emphasises that nutrition care in complex trauma should be continuous, flexible, and coordinated with surgical, critical-care, nursing, respiratory, and rehabilitation teams.

References

  1. Compher C, Bingham AL, McCall M, et al. Guidelines for the provision of nutrition support therapy in the adult critically ill patient: the American Society for Parenteral and Enteral Nutrition. JPEN J Parenter Enteral Nutr. 2022;46(1):12–41. doi:10.1002/jpen.2267.ncbi.nlm.nih
  2. Singer P, Blaser AR, Berger MM, et al. ESPEN guideline on clinical nutrition in the intensive care unit. Clin Nutr. 2019;38(1):48–79. doi:10.1016/j.clnu.2018.08.037.clinicalnutrition
  3. Singer P, Reintam Blaser A, Berger MM, et al. ESPEN practical and partially revised guideline: clinical nutrition in the intensive care unit. Clin Nutr. 2023;42:1671–1689.espen
  4. Cederholm T, Jensen GL, Correia MITD, et al. GLIM criteria for the diagnosis of malnutrition: a consensus report from the global clinical nutrition community. Clin Nutr. 2019;38(1):1–9. doi:10.1016/j.clnu.2018.08.002.ncbi.nlm.nih
  5. Detsky AS, McLaughlin JR, Baker JP, et al. What is subjective global assessment of nutritional status? JPEN J Parenter Enteral Nutr. 1987;11(1):8–13. doi:10.1177/014860718701100108.

Nightingale Journals

Kauvery Hospital
Find Doctor
Book Appointment