Peggy White

Nutrition and metabolic support for critically ill patients.

Purpose of review Acute critical illness increases the risk of malnutrition, are more obese, and have multiple comorbidities and frequent pre-existing nutritional deficits. There is a vast amount of research and literature being written on nutritional practices in the critically ill. We review and discuss herein the important nutrition literature over the past 12 months. Recent findings Sarcopenia, defined as loss of skeletal mass and strength, is associated with increased mortality and morbidity, particularly in elderly patients with trauma. Ultrasound is emerging as a noninvasive and promising method of measuring muscularity. Measuring gastric residuals and postpyloric feeding may not decrease rates of pneumonia in critically ill patients. Trophic and full feeding lead to similar long-term functional and cognitive outcomes in patients with acute respiratory distress syndrome. Summary Nutrition and metabolic support of critically ill patients is a complex and diverse topic. Nutritional measurements, requirements, and modes and routes of delivery are currently being studied to determine the best way to treat these complicated patients. We present just a few of the current controversial topics in this fascinating arena.

Long-Term Outcomes for Different Forms of Stress Cardiomyopathy After Surgical Treatment for Subarachnoid Hemorrhage.

BACKGROUND:Stress-induced cardiomyopathy (SCM) after subarachnoid hemorrhage (SAH) includes predominant apical or basal regional left ventricular dysfunction (RLVD) with concomitant changes in electrocardiogram or increase in cardiac enzymes. We hypothesized that difference in outcome is associated with the type of RLVD after SAH. METHODS:We studied a single-center retrospective cohort of SAH patients hospitalized between 2000 and 2010 with follow-up until 2013. We classified patients who had an echocardiogram for clinically indicated reasons according to the predominate location of RLVD as classic SCM-apical form and variant SCM-basal form. A Cox proportional hazard model and logistic regression were used to estimate the risk for death and hospital complications associated with different RLVD after adjustment for propensity to undergo echocardiography given clinical characteristics on admission. RESULTS:Among 715 SAH patients, 28% (200/715) had an echocardiogram for clinical evidence of cardiac dysfunction during hospitalization, the most common being acute left ventricular dysfunction, suspected acute ischemic event, changes in electrocardiogram and cardiac enzymes, and arrhythmia. SCM was present in 59 patients (8% of all cohort and 30% of patients with echocardiogram, respectively) with similar distribution of SCM-basal (25/59) and SCM-apical forms (34/59). SAH patients who had an echocardiogram for clinically indicated reasons had a significantly decreased risk-adjusted long-term survival compared with those without an echocardiogram, regardless of the presence of RLVD. SCM-basal form was associated with cardiac complications (odds ratio, 6.1; 99% confidence interval, 1.8–20.2) and severe sepsis (odds ratio, 5.3; 99% confidence interval, 1.6–17.2). CONCLUSIONS:SAH patients with echocardiogram for a clinically indicated reason have a decreased long-term survival, regardless of the presence of RLVD. The association between severe sepsis and SCM-basal warrants future studies to determine their potential synergistic effect on left ventricular systolic dysfunction among SAH patients.

Ventilator-associated Events: What Does It Mean?

1240 www.anesthesia-analgesia.org November 2015 • Volume 121 • Number 5 Copyright

End-of-life discussions: Who's doing the talking?

Purpose: To determine, in a tertiary academic medical center, the reported frequency of end‐of‐life discussions among nurses and the influence of demographic factors on these discussions. Methods: Survey of nurses on frequency of end‐of‐life discussions in two urban academic medical centers. Chi‐square tests were used to separately assess the relationship between age, gender, specialty, and experience with responses to the question, “Do you regularly talk with your patients about end‐of‐life wishes?” Results: Overall, more than one‐third of respondents reported rarely or never discussing end‐of‐life wishes with their patients. Only specialty expertise (p < 0.001) was statistically significantly associated with discussing end‐of‐life issues with patients. Over half of nurses specializing in critical care responded that they have these discussion “always” or “most of the time.” However, for the specialties of surgery (59%) and anesthesiology (56%), the majority of respondents reported rarely or never having end‐of‐life discussions with patients. Conclusions: In a survey conducted in two tertiary care institutions, more than one‐third of nurses from all disciplines responded that they never or almost never discuss end‐of‐life issues with their patients. Specialty influenced the likelihood of discussing end‐of‐life issues with patients.

Academic Productivity of Accreditation Council for Graduate Medical Education-Accredited Critical Care Fellowship Program Directors.

Objectives:Academic productivity is an expectation for program directors of Accreditation Council for Graduate Medical Education–accredited subspecialty programs in critical care medicine. Within the adult critical care Accreditation Council for Graduate Medical Education–accredited programs, we hypothesized that program director length of time from subspecialty critical care certification would correlate positively with academic productivity, and primary field would impact academic productivity. Design:This study received Institutional Review Board exemption from the University of Florida. Data were obtained from public websites on program directors from all institutions that had surgery, anesthesiology, and pulmonary Accreditation Council for Graduate Medical Education–accredited subspecialty critical care training programs during calendar year 2012. Information gathered included year of board certification and appointment to program director, academic rank, National Institutes of Health funding history, and PubMed citations. Results:Specialty area was significantly associated with total (all types of publications) (p = 0.0002), recent (p < 0.0001), last author (p = 0.008), and original research publications (p < 0.0001), even after accounting for academic rank, years certified, and as a program director. These differences were most prominent in full professors, with surgery full professors having more total, recent, last author, and original research publications than full professors in the other critical care specialties. Conclusions:This study demonstrates that one’s specialty area in critical care is an independent predictor of academic productivity, with surgery having the highest productivity. For some metrics, such as total and last author publications, surgery had more publications than both anesthesiology and pulmonary, whereas there was no difference between the latter groups. This suggests that observed differences in academic productivity vary by specialty.

Nutrition in the Neurointensive Care Unit

Approximately 30–50 % of hospitalized patients worldwide suffer from malnutrition, making the importance of maintaining adequate nutritional support crucial to critically ill patients. Achieving an adequate level of nutritional support revolves around counteracting hypermetabolic effects of injury or illness by reducing the severity of malnutrition and preventing complications such as overfeeding. Early recognition, prevention, and appropriate initiation of supplemental nutrition will aid in optimizing nutritional status. Patients able to reach and maintain an optimal level of nutritional status will benefit from faster recovery, improved wound healing, and an increase in rehabilitative efforts. Likewise, a decrease in hospital length of stay, complication rates, morbidity, and mortality will occur.