Keith R. Miller

Summary points and consensus recommendations from the North American Surgical Nutrition Summit.

http://pen.sagepub.com/content/37/5_suppl/99S The online version of this article can be found at: DOI: 10.1177/0148607113495892 2013 37: 99S JPEN J Parenter Enteral Nutr Beth Taylor and Paul E. Wischmeyer Drover, David Flum, Leah Gramlich, David N. Herndon, Clifford Ko, Kenneth A. Kudsk, Christy M. Lawson, Keith R. Miller, Stephen A. McClave, Rosemary Kozar, Robert G. Martindale, Daren K. Heyland, Marco Braga, Francesco Carli, John W. Summary Points and Consensus Recommendations From the North American Surgical Nutrition Summit

The evolving management of venous bullet emboli: a case series and literature review.

Bullet emboli are an infrequent and unique complication of penetrating trauma. Complications of venous and arterial bullet emboli can be devastating and commonly include limb-threatening ischaemia,pulmonary embolism, cardiac valvular incompetence, and cerebrovascular accidents. Bullets from penetrating wounds can gain access to the venous circulation and embolise to nearly every large vascular bed. Venous emboli are often occult phenomenon and may remain unrecognised until migration leads to vascular injury or flow obstruction with resultant oedema. The majority of arterial emboli present early with end-organ or limb ischaemia. We describe four separate cases involving venous bullet embolism and the subsequent management of each case. Review of the literature focusing on the reported management of these injuries, comparison of techniques of management, as well as the evolving role of endovascular techniques in the management of bullet emboli is provided.

Can the Intestinal Dysmotility of Critical Illness be Differentiated from Postoperative Ileus

Gastrointestinal dysmotility is commonly noted in the intensive care unit and postoperative settings. Characterized by delayed passage of stool and flatus, nausea, vomiting, and abdominal distention, the condition is associated with nutritional deficiencies, risk of aspiration, and considerable allocation of health care resources. Knowledge of gastrointestinal function in health and illness continues to expand. While the factors that precipitate ileus differ between postoperative and critically ill patients, the two clinical scenarios seem to have similar mechanisms and share many of the same pathophysiologic patterns. By reviewing and comparing the literature on the respective mechanisms and contributing factors generated in these separate clinical settings, a common more comprehensive management strategy may be derived with the potential for newer innovative therapeutic options.

Nutrition therapy issues in esophageal cancer.

Esophageal cancer has traditionally been a disease with poor long term outcomes in terms of both survival and quality of life. In combination with surgical and pharmacologic therapy, nutrition support has been demonstrated to improve patient tolerance of treatment, quality of life, and longterm outcomes. An aggressive multi-disciplinary approach is warranted with nutrition support remaining a cornerstone in management. Historically, nutrition support has focused on adequate caloric provision to prevent weight loss and allow for tolerance of treatment regimens. Alterations in metabolism occur in these patients making their use of available calories inefficient and the future of nutritional support may lie in the ability to alter this deranged metabolism. The purpose of this article is to review the current literature surrounding the etiology, treatment, and role of nutrition support in improving outcomes in esophageal cancer.

An Evidence-Based Approach to Perioperative Nutrition Support in the Elective Surgery Patient

In surgical practice, great attention is given to the perioperative management of the elective surgical patient with regard to surgical planning, stratification of cardiopulmonary risk, and postoperative assessment for complication. However, growing evidence supports the beneficial role for implementation of a consistent and literature-based approach to perioperative nutrition therapy. Determining nutrition risk should be a routine component of the preoperative evaluation. As with the above issues, this concept begins with the clinicians first visit with the patient as risk is assessed and the severity of the surgical insult considered. If the patient is an appropriate candidate for benefit from preoperative support, a plan for initiation and reassessment should be implemented. Once appropriate nutrition end points have been achieved, special consideration should be given to beneficial practices the immediate day preceding surgery that may better prepare the patient for the intervention from a metabolic standpoint. In the operating room, consideration should be given to the potential placement of enteral access during the index operation as well as judicious and targeted intraoperative resuscitation. Immediately following the intervention, adequate resuscitation and glycemic control are key concepts, as is an evidence-based approach to the early advancement of an enteral/oral diet in the postoperative patient. Through the implementation of perioperative nutrition therapy plans in the elective surgery setting, outcomes can be improved.

The prevalence and impact of prescription controlled substance use among injured patients at a Level I trauma center

BACKGROUND There has been increasing attention focused on the epidemic of prescription drug use in the United States, but little is known about its effects in trauma. The purpose of this study was to define the prevalence of prescription controlled substance use among trauma patients and determine its effects on outcome. METHODS A retrospective review of all patients admitted to a Level 1 trauma center from January 1, 2011, to December 31, 2011, was performed. Patients dying within 24 hours or without home medication reconciliations were excluded. Data review included preexisting benzodiazepine or narcotic use, sex, age, mechanism of injury, Injury Severity Scores (ISSs), intensive care unit (ICU) and overall length of stay, ventilator days, and overall cost. SAS version 9.3 was used for the analysis, and p ⩽ 0.05 was considered significant. RESULTS A total of 1,700 patients met inclusion criteria. Of these, 340 (20.0%) were on prescription narcotics and/or benzodiazepines at the time of admission. Patients in the narcotic/benzodiazepine group were significantly older (48 years vs. 43 years) and more likely to be women (43.7% vs. 28.9%). There was no difference in mechanism, ISS, or the presence of head injury between groups. Both ICU length of stay (3.3 days vs. 2.1 days) and total length of stay (7.8 days vs. 6.1 days) were significantly longer in patients on outpatient narcotics and/or benzodiazepines. Excluding severely injured patients, the need for mechanical ventilation was also increased among outpatient controlled substance users (15.8% vs. 11.0%). CONCLUSION There is a substantial prevalence of preexisting controlled substance use (20%) among patients at our Level 1 trauma center. Preexisting controlled substance use is associated with longer total hospital and ICU stays. Among mildly to moderately injured patients, preinjury controlled substance is also associated with the need for mechanical ventilation. LEVEL OF EVIDENCE Prognostic study, level III.

When Is It Appropriate to Use Arginine in Critical Illness

In health, arginine is considered a nonessential amino acid but can become an essential amino acid (ie, conditionally essential amino acid) during periods of metabolic or traumatic stress as endogenous arginine supply is inadequate to meet physiologic demands. Arginine depletion in critical illness is associated with impairments in microcirculatory blood flow, impaired wound healing, and T-cell dysfunction. The purpose of this review is to (1) describe arginine metabolism and role in health and critical illness, (2) describe the relationship between arginine and asymmetric dimethylarginine, and (3) review studies of supplemental arginine in critically ill patients.

Appropriate Protein and Specific Amino Acid Delivery Can Improve Patient Outcome: Fact or Fantasy?

Protein utilization and requirements in critical illness are much researched and debated topics. The enhanced turnover and catabolism of protein in the setting of critical illness is well described and multifactorial in nature. The need to preserve lean body mass and enhance nitrogen retention in this state to improve immunologic function and reduce morbidity is well described. Debates as to the optimum amount of protein to provide in such states still exist, and a significant amount of research has contributed to our understanding of not only how much protein to supply to these patients, but how best to do so. Small peptide formulations, intact protein formulations, branched chain amino acids, and specialty formulas all exist, and their benefits, drawbacks, and potential uses have been investigated. Specific amino acid therapy has become part of the concept of immunonutrition, or the modification and enhancement of the immune response with specific nutrients. In this article, we describe the changes in outcomes demonstrated through the provision of protein, both as a macronutrient and as specific amino acids.

Does chest tube location matter? An analysis of chest tube position and the need for secondary interventions.

BACKGROUND Tube thoracostomy is a common procedure used in the management of thoracic trauma. Traditional teaching suggests that chest tubes should be directed in specific locations to improve function. Common examples include anterior and superior placement for pneumothorax, inferior and posterior placement for hemothorax, and avoidance of the pulmonary fissure. The purpose of this study was to examine the effect of specific chest tube position on subsequent chest tube function. METHODS A retrospective review of all patients undergoing tube thoracostomy for trauma from January 1, 2010, to September 30, 2012, was performed. Only patients undergoing computed tomography scans following chest tube insertion were included so that positioning could be accurately determined. Rib space insertion level and positioning of the tube relative to the lung parenchyma were recorded. The duration of chest tube drainage and the need for secondary interventions were determined and compared for tubes in different rib spaces and locations. For purposes of comparison, tubes placed above the sixth rib space were considered “high,” and those at or below it were considered “low.” RESULTS A total of 291 patients met criteria for inclusion. Forty-eight patients (16.5%) required secondary intervention. Neither high chest tube placement nor chest tube location relative to lung parenchyma was associated with an increased need for secondary interventions. On multivariate analysis, only chest Abbreviated Injury Scale (AIS) scores, mechanism, and volume of hemothorax were found to be significant risk factors for the need for secondary interventions. CONCLUSION Chest tube location does not influence the need for secondary interventions as long as the tube resides in the pleural space. The severity of chest injury is the most important factor influencing outcome in patients undergoing tube thoracostomy for trauma. Tube thoracostomy technique should focus on safe insertion within the pleural space and not on achieving a specific tube location. LEVEL OF EVIDENCE Therapeutic study, level IV.

A Tutorial on Enteral Access in Adult Patients in the Hospitalized Setting

Enteral access is a cornerstone in the provision of nutrition support. Early and adequate enteral support has consistently demonstrated improved patient outcomes throughout a wide range of illness. In patients unable to tolerate oral intake, multiple options of delivery are available to the clinician. Access requires a multidisciplinary effort that involves nurses, dietitians, and physicians to be successful. These techniques and procedures are not without morbidity and even mortality. A comprehensive understanding of the appropriate management of these tubes and their inherent complications should be garnered by all those involved with nutrition support teams. This tutorial reviews available options for enteral access in addition to commonly encountered complications and their management.