Experience with enteral nutrition in a hospital population of acutely ill patients.

Enteral feeding has unique metabolic and immune advantages. This article describes the successful use of enteral nutrition, alone or in combination with parenteral feeding, in a tertiary-care hospital. Study participants were 89 patients who received enteral feeding during a 6-month period. These critically ill patients (ranging in age from 55 to 71 years) had severity of illness levels of 7 to 25 according to the Acute Physiologic and Chronic Health Evaluation (APACHE II) system and lengths of hospital stay from 27 to 73 days. Mortality was as high as 50% in patients with liver disease (nonmalignant), 35% in patients with cardiothoracic and vascular diseases, and 17% in patients with cancer and other diseases. Despite the severity of illness, patients met their energy and protein intake goals through enteral or combined feeding with total parenteral nutrition. Serial weights (ie, obtained weekly) and serum albumin concentrations did not improve during hospitalization. Complications related to enteral feeding were minimal (< 17% incidence). Differences were noted between survivors and nonsurvivors: nonsurvivors had lower serum albumin concentrations at the time of admission, had longer hospitalizations, and required total parenteral nutrition for more days than the survivors. Nonetheless, even with extremely sick patients, provision of enteral nutrition can be successful using the administration techniques we describe. Enteral nutrition could best be provided by beginning at a slow rate (10 c3/hour), inserting the feeding tube past the pylorus, and feeding according to sensible energy goals (25 kcal/kg of body weight), and using elemental then polymeric formulas.

Preoperative risk factors that predict hospital length of stay in coronary artery bypass patients > 60 years old.

BACKGROUND: The ability to predict prolonged length of stay (LOS) is essential to control escalating hospital costs. Operative mortality is a poor predictor of LOS; morbidity as defined by hospitalization for > 14 days after coronary artery bypass graft surgery (CABG), appears to be responsible for increasing costs. The purpose of this study was to measure preoperative predictive indicators of increased LOS with an eventual plan to offer alternative cost-benefit therapeutic options. METHODS AND RESULTS: Nine hundred twenty-four consecutive patients (age, 60-86 years) undergoing CABG were retrospectively studied by means of the Cox proportional hazards model. Seventeen variables, excluding death, were analyzed and quantified as to importance, and point totals were calculated for each patient. Scores were 12 for congestive heart failure and intra-aortic balloon assist device; 10, creatinine > 2; 6, intra-aortic balloon assist device only; 5, congestive heart failure only; 3, obesity; 6, age > 75 years; 3, age 70-75 years; and 2, 65-69 years. CONCLUSIONS: Increasing index score directly correlated with an exponential increase in LOS. These data substantiate the hypothesis that a mathematical model can predict LOS in CABG patients and may offer rational alternative strategies in delivering cost-effective health care.

Reevaluation of current transfusion practices in patients in surgical intensive care units.

Widespread interest in the complications associated with packed red blood cell (PRBC) transfusions has led to the scrutiny of traditional transfusion practices. Recently, attempts have been made to define more clearly the indications for PRBC transfusions in patients, particularly those who are critically ill. At present, however, transfusions continue to be ordered based on a hemoglobin level less than 10 g/dL. We report herein the impact on oxygen consumption of PRBC transfusions administered for a hemoglobin concentration less than 10 g/dL in 30 surgical intensive care unit patients who were euvolemic and hemodynamically stable. For the group as a whole, transfusion had a negligible effect on oxygen consumption. Fifty-eight percent of all such transfusions failed to change oxygen consumption by greater than 10% and could therefore be considered of questionable benefit.

Intra-abdominal sepsis and adrenergic receptor response.

This study measured the adrenergic receptor response of 13 patients with severe intra-abdominal sepsis, who required laparotomy and an open abdominal closure with Marlex mesh. The source of the sepsis was gram-negative organisms of intestinal origin. There were seven survivors and six nonsurvivors. When the patients were stratified into survivors and nonsurvivors, the Septic Severity Score, the APACHE II score, the Acute Physiological Score, and the Glasgow Coma Scale score results were not significantly different between groups. The alpha-2 and beta-1 adrenergic receptor responses were measured in the adipose tissue of the abdominal wall and the small bowel mesentery on day 1 of admission to the intensive care unit. The results demonstrated that the alpha-2 and beta-1 receptors of the nonsurvivors had a significantly decreased receptor response with desensitization and down regulation. The alpha-2 and beta-1 receptors of the survivors had an increased response with hypersensitization and up regulation. This study indicates that the adrenergic receptor pattern is distinctly different between survivors and nonsurvivors with severe abdominal gram-negative sepsis. The pattern differences occurred early (within 24 hours) when the patients had similar physiologic profiles. It is concluded that adrenergic receptor response may be a biologic indicator of the magnitude of the septic injury and a predictor of outcome.

Glutamine content of whole proteins: implications for enteral formulas.

In two recent clinical trials in surgical patients, supplementation of total parenteral nutrition with daily doses of 12 or 20 g of glutamine resulted in a diminished loss of free glutamine in skeletal muscle tissue. Studies in animals exploring the use of both enteral and parenteral glutamine supplementation suggest that glutamine may be an essential nutrient in the maintenance of gut structure and function during critical illness. These findings have led to heightened interest in the glutamine content of enteral formulas. This article describes a method for estimating the glutamine content of whole-protein enteral formulas. The average amount of glutamine in selected, whole-protein formulas ranges from a minimum of 3.55 g/4200 kJ to a maximum of 5.15 g/4200 kJ. Although it is still too early to define the safest and most effective dose of glutamine, there are two points regarding glutamine supplementation that clearly merit further investigation: no clinical trials have been conducted to assess the potential benefits of glutamine supplementation of an enteral diet or to assess the effects of using diets containing protein-bound glutamine rather than free glutamine.

Tolerance to enteral tube feeding diets in hypoalbuminemic critically ill, geriatric patients.

Tolerance of elemental (for example, Peptamen [PEP]) or free amino acid (for example, Vivonex TEN [VIV]) tube feeding diets is controversial, especially in the critically ill patient who is hypoalbuminemic. A prospective, randomized trial was conducted to compare differences between feeding PEP (n = 8) or VIV (n = 8) in critically ill, elderly (average age of 66 years) patients. Diets were administered through nasogastric or postpyloric feeding tubes. Eleven patients had diseases of the gastrointestinal tract; all underwent surgical treatment. Patients were fed each diet at full strength, beginning with 20 to 30 milliliters per hour and advancing by 10 to 20 milliliters every day until goal rate was reached, usually on day 4. Assessment was made for ability to comply with rate of tube feeding ordered, compliance with caloric goal and tolerance (as evidenced by abdominal discomfort and diarrhea). Diarrhea was qualitatively defined as more than three stools per day and then quantitatively as the mean number of stools daily. There were no significant differences between the two groups in terms of compliance with prescribed tube feeding order or caloric goal or the presence of diarrhea and abdominal discomfort. There was a significant difference between the two groups in terms of the actual number of stools per day (PEP equals 1.38 versus VIV equals 2.25, p less than 0.02). Serum albumin concentrations upon initiation of the diets were 2.3 grams per deciliter in both groups. We conclude that tolerance to the two diets were similar because it was possible to feed enterally either PEP or VIV in critically ill, hypoalbuminemic patients (serum albumin concentrations of less than 2.5 grams per deciliter) successfully, irrespective of diet. Although there were more stools in the VIV group, this did not reduce compliance with the goals.

Impact of gastric restrictive surgery on hypertension in the morbidly obese.

Hypertension is a major health risk factor in patients who are morbidly obese. Two hundred eighty-nine morbidly obese patients undergoing gastric restrictive surgery were evaluated for the presence of hypertension (blood pressure greater than or equal to 160/90 mm Hg or currently undergoing antihypertensive therapy) pre- and postoperatively. Of 74 (26%) preoperatively hypertensive patients, 67 (91%) were available for follow-up. Preoperative hypertension resolved in 66% (44 of 67) of patients following gastric restrictive surgery. Superobese and morbidly obese patients had similar reductions in hypertension after surgery (69% versus 63%). Patients not receiving antihypertensives preoperatively had a greater reduction of hypertension than those medically treated preoperatively (78% versus 58%). The amount of weight loss significantly predicted the reduction of hypertension, whereas follow-up weight achieved did not. The amounts of weight loss for patients with resolved and persistent hypertension were 89.3 +/- 5.6 lbs (mean +/- standard error of the mean +ADSEM+BD) and 66.0 +/- 8.3 lbs, respectively (p less than 0.02). For patients with resolved hypertension, follow-up weights for the morbidly obese and superobese were 162.0 +/- 10.8 lbs (133% +/- 4% ideal body weight +ADIBW+BD) and 220.4 +/- 9.5 lbs (170% +/- 7% IBW). Gastric restrictive surgery is effective therapy for hypertension in morbidly obese patients. Patients need not achieve weights approaching IBW to enjoy the benefits of gastric restrictive surgery on hypertension.

Elective intrahospital admissions versus acute interhospital transfers to a surgical intensive care unit: cost and outcome prediction.

After a decade of intense fiscal scrutiny, appropriate utilization of intensive care resources remains controversial. In particular, the financial impact of patients transferred to a tertiary surgical intensive care unit (SICU) from a community hospital (interhospital) is unknown, especially when compared with elective (intrahospital) SICU admissions admitted from the tertiary center itself. We prospectively studied outcome and costs in 82 consecutive tertiary SICU admissions. Half were transferred acutely from community hospitals and half were transferred from within the hospital or postoperatively. Severity of illness (APACHE II) was scored on day 1, at the same time of the day (9:00-10:00 AM) and by one attending surgeon (BCB). Acute transfer patients had a significantly elevated mortality (36%) when compared with elective admissions (12%) (p less than 0.05). When stratified by APACHE II score, acute transfers had twice the mortality for equivalent APACHE II scores (p less than 0.05). Acute transfer patients with APACHE II scores greater than 19 had an 89% mortality; those nonsurvivors cost $128,652 each. From these results we conclude the following: (1) Acute transfer patients have a significantly elevated mortality when compared with elective intrahospital admissions with equivalent APACHE II day-1 scores; (2) patients transferred acutely to tertiary SICUs are significantly more costly, irrespective of outcome; (3) admission source (elective vs. acute transfer) should be seriously considered when evaluating patient outcome and cost in a SICU.

Surgical intensive care unit resource use in a specialty referral hospital: I. Predictors of early death and cost implications.

The rationing of medical care prioritizes the need for early predictors of death in the surgical intensive care unit (SICU). We prospectively studied 100 consecutive SICU admissions, looking for predictors of early death in the SICU and the cost implications of these findings. Serial APACHE II scores on days 1, 3, and 5 were subjected to multinomial logistic regression analysis to determine significant predictors of death in the SICU on day 1. Survivors had significantly lower (p less than 0.05) mean day-1 APACHE II scores than had nonsurvivors (13.6 vs 22.1). Half of the patients with scores greater than 18 died, and all patients with scores on day 1 of 25 or greater died. Significant predictors of death on SICU day 1 were APACHE II scores, Acute Physiology Score, Glasgow Coma Score, creatinine level, and Chronic Health Evaluation Score. Forty-one patients had been transferred from community hospitals as a results of acute illness; this population accounted for two thirds of the deaths in the SICU. Ten of 18 nonsurvivors were predicted on day 1, with these patients incurring a total cost of approximately $1 million. If therapy had been modified on days 5, 10, or 15, the potential cost savings would have been $340,000, $240,000, or $140,000, respectively. Integration of the results of this study into the management decision-making process and treatment guidelines may reduce the cost of care in the SICU.

The abdominal trauma index--a critical reassessment and validation.

The Abdominal Trauma Index (ATI) was devised to quantify the risk of complications following abdominal trauma. With scores greater than 25, the risk of postoperative complications became exponential. The purpose of the present study was to determine if: 1) the organ risk factors previously assigned were more statistically valid; and 2) the addition of physiologic variables would enhance the prediction of postinjury intra-abdominal sepsis. Fifteen abdominal organ systems and 17 physiologic variables in 300 consecutive patients were analyzed to determine ability to predict intraabdominal sepsis. There were no significant differences in predictive ability between the old and new organ risk factors. The addition of physiologic factors did not enhance the prediction of intra-abdominal sepsis. This clinical study demonstrates that: 1) the risk of intra-abdominal sepsis increases with increasing ATI score; 2) the previous (1979-initial) organ risk grading concept is statistically valid; 3) six of the 15 organ systems warrant a change in their relative rank order (1989-revision); 4) the addition of demographic, physiologic, and immunologic variables did not significantly improve the prediction of intra-abdominal sepsis.

Albumin supplementation in the critically ill. A prospective, randomized trial.

Albumin replacement to correct hypoalbuminemia in critically ill patients has been controversial. This study was a prospective, randomized trial of 25% albumin administration in 40 hypoalbuminemic (serum albumin, less than 25 g/L [2.5 g/dL]), critically ill patients. The treatment group (18 patients) received 25% albumin supplementation to achieve and maintain serum albumin levels of 25 g/L (2.5 g/dL) or greater, while the nontreatment group (22 patients) received no concentrated albumin. There was no clinical benefit from albumin therapy when assessing mortality (39% vs 27%, treatment vs control) or major complication rate (89% vs 77% of patients). There were also no significant differences in length of hospital stay, intensive care unit stay, ventilator dependence, or tolerance of enteral feeding, despite significant elevations of albumin in the treatment group. The costly use of exogenous albumin as treatment for hypoalbuminemia in this patient population does not appear to be justified.

Work of breathing: reliable predictor of weaning and extubation.

During the course of a critical illness, many patients become ventilator dependent. The standard assessment criteria are not always accurate in predicting potential for extubation. This investigation was designed to analyze whether the work of breathing (WOB) was a more reliable predictor of ventilator dependence. Twenty consecutive ventilator-dependent patients were prospectively studied. Nineteen required ventilator support for greater than 2 wk and all were considered ventilator dependent because of their inability to tolerate weaning trials. The oxygen consumption (VO2) and resting energy expenditure were measured using a metabolic gas monitor. Respiratory mechanics and arterial blood gas measurements were obtained, and the deadspace to tidal volume ratio (VD/VT) was calculated. The WOB was determined by the difference in VO2 between spontaneous and mechanical ventilation, and expressed as a percentage of VO2 during mechanical ventilation. Five of eight patients with a WOB less than 15% (mean 1.9) were extubated within 2 wk of study, while none of 12 patients with a WOB greater than or equal to 15% (mean 34) were able to be extubated in this period. The differences in the WOB between the two groups were statistically significant (p less than .01), while there was no significant difference in mechanics, PaCO2, VD/VT or measured resting energy expenditure. These data support the use of WOB determinations in evaluating extubation potential. Using a reference value for the WOB of 15%, this study had a sensitivity of 100% and a specificity of 80%. This proved to be of greater predictive value than traditional criteria.

Penetrating wounds to the posterior chest: analysis of exigent thoracotomy and laparotomy.

Most reports of penetrating chest wounds include all regions of the thoracic wall. Recent studies of abdominal wounds stratified by entrance site have demonstrated significant differences in injury pattern that influence initial assessment and management. This is an analysis of 135 consecutive patients admitted to the Denver General Hospital with penetrating injuries to the posterior chest, done in an effort to elucidate operative indications. Fifteen of these patients required emergency department (ED) thoracotomy and were excluded from the study. In the remaining 120 patients, mechanism was gunshot (GSW) in 20% and stab wound (SW) in 80%; 89% were men, and the mean age was 26 years. For analysis, the posterior chest was further divided into upper and lower at the inferior tip of the scapula line. Overall, 28 patients (23%) with posterior penetrating chest wounds required early surgical intervention; 38% following a GSW compared to 20% due to a SW. Only 9 patients (8%) required thoracotomy while 19 (15%) underwent laparotomy. The most frequent indication for thoracotomy was persistent chest hemorrhage, and for laparotomy, positive diagnostic peritoneal lavage.

Penetrating wounds to the anterior chest. Analysis of thoracotomy and laparotomy.

This study of the records of 193 consecutive patients admitted for penetrating anterior chest wounds was carried out to specifically define the need for emergent thoracotomy or laparotomy. The mechanism of injury was a stab wound in 119 patients and a gunshot wound in 74 patients. Seventy-three of the patients (38 percent) required either early thoracotomy (21 percent) or laparotomy (17 percent). In the upper chest region, 83 percent of the operations were thoracotomies, whereas in the lower chest region, 81 percent were laparotomies. Pericardial tamponade, chest tube output, and hypovolemic shock comprised 91 percent of the decisive signs for thoracotomy. The predominant reason for laparotomy was diagnostic peritoneal lavage (63 percent of patients). Plain abdominal roentgenograms were helpful to confirm diaphragmatic missile traverse. Our findings support selective operative management of anterior chest wounds as guided by injury mechanism and entrance location.

A prospective study of preoperative chemotherapy and split-course irradiation for locally advanced or recurrent oral/pharyngeal squamous carcinoma.

Two courses of preoperative chemotherapy (methotrexate, bleomycin, cisplatin) were combined with split-course irradiation (2,000 rad/10 preop., 4,000 rad/20 postop.) and prospectively compared with standard therapy (surgery and/or irradiation alone) for locally advanced or recurrent oral/pharyngeal squamous cancer. The chemoradiotherapy arm (Ch-XRT) had 31 patients; the standard therapy arm 28 randomized (RC) and 20 concomitantly-treated (CC) patients. Treatment-related mortality was 17% for Ch-XRT; 10% for RC + CC. Number of patients NED at completion of treatment was 74% for Ch-XRT; 83% for RC + CC (NS). Median survival, however, was 17 months for Ch-XRT, 9 months for CC, and 12 months for RC. In addition, survival at 40 + months was 45% for Ch-XRT versus 21-22% for RC and CC (p less than 0.05). Thus, Ch-XRT seems to have promise in advanced oral/pharyngeal cancer, but needs revision to decrease toxicity.