Prospective randomized control trial of intermittent versus continuous gastric feeds for critically ill trauma patients.

BACKGROUND: This study compared an intermittent feeding regimen (one-sixth of daily needs infused every 4 hours) with a continuous (drip) feeding regimen for critically ill trauma patients. There were two outcome variables: time to reach goal volume and the days on 100% of caloric needs via an enteral route in the first 10 days of the intensive care unit stay. Adverse events were also tallied. METHODS: A prospective randomized trial was conducted in the trauma intensive care unit in a university Level I trauma center. A total of 164 trauma patients, 18 years of age and older were admitted to the trauma intensive care unit with a noninjured gastrointestinal tract and required more than 48 hours of mechanical ventilation. Patients were randomized to receive enteral nutrition via an intermittent feeding regimen versus a continuous feeding regimen. A single nutritionist calculated caloric and protein goals. A strict protocol was followed where hourly enteral intake, interruptions and their causes, diarrhea, and pneumonia were recorded, as well as standard guidelines for intolerance. RESULTS: A total of 164 patients were randomized and 139 reached their calculated nutritional goal within 7 days. There were no statistical differences in complications of tube feeding. The patients intermittently fed reached the goal faster and by day 7 had a higher probability of being at goal than did the patients fed continuously (chi = 6.01, p = 0.01). Intermittent patients maintained 100% of goal for 4 of 10 days per patient (95% CI = 3.5-4.4) as compared with the drip arm goal for only 3 of 10 days per patient (95% CI = 2.7-3.6). CONCLUSIONS: Patients from both the intermittent and continuous feeding regimens reached the goal during the study period of 7 days but the intermittent regimen patients reached goal enteral calories earlier. The intermittent gastric regimen is logistically simple and has equivalent outcomes to a standard drip-feeding regimen.

A burn mass casualty event due to boiler room explosion on a cruise ship: preparedness and outcomes.

The purpose of this study was to review our experience with a mass casualty incident resulting from a boiler room steam explosion aboard a cruise ship. Experience with major, moderate, and minor burns, steam inhalation, mass casualty response systems, and psychological sequelae will be discussed. Fifteen cruise ship employees were brought to the burn center after a boiler room explosion on a cruise ship. Eleven were triaged to the trauma resuscitation area and four to the surgical emergency room. Seven patients were intubated for respiratory distress or airway protection. Six patients had >80 per cent burns with steam inhalation, and all of these died. One of the 6 patients had 99 per cent burns with steam inhalation and died after withdrawal of support within the first several hours. All patients with major burns required escharotomy on arrival to trauma resuscitation. One patient died in the operating room, despite decompression by laparotomy for abdominal compartment syndrome and pericardiotomy via thoracotomy for cardiac tamponade. Four patients required crystalloid, 20,000 mls/m2-27,000 ml/m2 body surface area (BSA) in the first 48 hours to maintain blood pressure and urine output. Three of these four patients subsequently developed abdominal compartment syndrome and died in the first few days. The fourth patient of this group died after 26 days due to sepsis. Five patients had 13-20 per cent bums and four patients had less than 10 per cent burns. Two of the patients with 20 per cent burns developed edema of the vocal cords with mild hoarseness. They improved and recovered without intubation. The facility was prepared for the mass casualty event; having just completed a mass casualty drill several days earlier. Twenty-six beds were made available in 50 minutes for anticipated casualties. Fifteen physicians reported immediately to the trauma resuscitation area to assist in initial stabilization. The event occurred at shift change; thus, adequate support personnel were instantaneously to hand. Our mass casualty preparation proved useful in managing this event. Most of the patients who survived showed signs of post-traumatic stress syndrome, which was diagnosed and treated by the burn center psychology team. Despite our efforts at treating large burns (>80%) with steam inhalation, mortality was 100 per cent. Fluid requirements far exceeded those predicted by the Parkland (Baxter) formula. Abdominal compartment syndrome proved to be a significant complication of this fluid resuscitation. A coordinated effort by the facility and preparation for mass casualty events are needed to respond to such events.