Rafael Barrera

Predictive respiratory complication quotient predicts pulmonary complications in thoracic surgical patients

BACKGROUNDnThis study was designed to develop an accurate preoperative index of prediction of outcome and hospital charges after lung resection with standard available pulmonary tests in a tertiary cancer center.nnnMETHODSnSixty-one consecutive patients undergoing pulmonary resections were evaluated. All patients underwent spirometry, carbon monoxide diffusion capacity, split lung function testing, and room air blood gas analysis at rest and after a 2-minute step climb. The thoracic prospective data base and patient charts were reviewed for length of hospitalization, postoperative length of stay, and complications requiring therapy. Logistic regression analysis of the preoperative data, operation and postoperative outcome was used to develop a new postoperative predictive index: the predictive respiratory complication quotient (PRQ). We describe the design of the equation for the probability of serious pulmonary complications, hospital stay, and hospital charges based on PRQ.nnnRESULTSnTen of 12 patients with a PRQ less than 2,200 suffered serious pulmonary complications of pneumonia, respiratory insufficiency, hypoxemia, and death. Forty-nine patients with a PRQ more than 2,200 did not experience any pulmonary complications. Postoperative length of stay and hospital charges correlated with the PRQ.nnnCONCLUSIONSnA construct such as the PRQ may provide a better prediction of outcome than its individual parts. We identified an important underlying relationship between intensive care unit stay, hospital stay and charges, and our index. A PRQ of less than 2,200 was associated with an increased risk of pulmonary complications and mortality.

NUTRITIONAL SUPPORT IN CRITICALLY ILL PATIENTS WITH CANCER

Nutritional depletion is a common problem seen in critically ill patients with cancer and is associated with increased morbidity and mortality. Infection and injury activate a cascade of metabolic events that leads to a poor nutritional state and wasteful energy consumption. The goals of nutritional support entail minimizing starvation, preventing nutrient deficiencies, supporting or improving immune function, and facilitating tissue repair and wound healing. Further understanding of the metabolic changes of illness will improve effective regulation of the inflammatory events occurring in critically ill patients. Multiple clinical parameters are available to assess the nutritional status in critically ill patients, but no standard recommendations can be made at this time. The use of these parameters can be appropriate, provided that their limitations are understood clearly. The development and standardization of objective parameters to identify patients at risk or with subclinical malnutrition are needed. Enteral and parenteral feedings are safe and effective methods to deliver nutrients to critically ill patients with cancer who are unable to ingest adequate amounts orally. Early nutritional support should be instituted in the appropriate clinical setting. Specialized nutritional solutions and supplements require careful consideration in patients with renal, hepatic, cardiac, or pulmonary disorders. The unselective use of nutritional support is not indicated in well-nourished patients with cancer undergoing surgery, chemotherapy, or radiotherapy in whom adequate oral intake is anticipated. Nutritional support remains an important adjunctive therapy in the overall management of critically ill patients. Continued clinical investigations in nutrition are necessary to identify other groups of patients who can benefit from nutritional interventions.

Clinical Research: Outcome of Home Enteral Nutrition in Patients with Malignant Dysphagia

Neoplastic diseases account for approximately one-half of all patients receiving home enteral nutrition, most of them with dysphagia due to the underlying cancer or antineoplastic therapies (malignant dysphagia). A review of the records of all patients with malignant dysphagia receiving home enteral nutrition for greater than 1 year was undertaken. The following factors were identified: age, primary cancer, type of enteral access, calories received, duration of therapy, complications, and need for tube replacement. Eighty-two patients were studied. On average, patients received 1978 cal/day (range: 500 to 3000) and were maintained on home enteral nutrition for 976 days (range: 367 to 3026). Complications at the tube site were infection in 4 patients (4.8%) and significant leakage in 2 patients (2.4%). Average durability of the enteral access devices was percutaneous endoscopic gastrostomies (PEG) = 690 days, low profile gastrostomy = 1701 days, percutaneous endoscopic jejunostomies (PEJ) = 591 days, low-p...

Flow triggering added to pressure support ventilation improves comfort and reduces work of breathing in mechanically ventilated patients

PURPOSEnThe purpose of this study was to measure the effect of flow triggering (FT), added to pressure support ventilation (PSV), during spontaneous breathing in intubated patients.nnnMATERIALS AND METHODSnA prospective observational study was conducted at a Comprehensive Cancer Center, University Hospital. Fourteen consecutive critically ill, mechanically ventilated patients on PSV with positive end-expiratory pressure were studied. Flow triggering was added to PSV in spontaneously breathing ventilated patients.nnnRESULTSnRespiratory rate (f), minute ventilation (Vepsilon), patient work of breathing (WOBp), respiratory drive (P0.1), rapid shallow breathing index (f/Vt), tidal volume (Vt) and a visual analog scale of breathing effort and comfort all improved. There was a large decrease in WOBp and P0.1 when flow triggering was added to PSV (P<.001). There was a moderate decrease in f/V1 during the same procedure (P<.01). Twelve patients felt subjectively better with the intervention.nnnCONCLUSIONSnFlow triggering offers an excellent complement to PSV because it improves patient comfort and reduces the magnitude of the inspiratory effort as well as the delay time between inspiratory muscle contraction and gas flow. It augments gas exchange at no metabolic cost to the patient while reducing the work of breathing.

Body Mass Index as a Predictor of Complications and Length of Hospital Stay after Thoracic Surgery

Background: Body mass index (BMI) has been correlated to complications and outcome in surgical patients at the two extremes of the nutrition spectrum. Objective: To study the relationship between BMI, outcome, hospital length of stay and complications in oncology patients undergoing thoracic surgery. Design: The study population was divided according to BMI in normal weight patients (BMI = 18 to 25) and ovenveight patients (BMI > 25) and prospectively followed postoperative cardiac complications, pulmonary complications, and death. Charts were reviewed for length of hospital stay. Results: One hundred thirty-seven patients were studied. There were a total of 53 complications in 39 of 137 patients (BMI 26 ± 4). Thirty-five (25%) were pulmonary and 18 (13%) were cardiac complications. There was no correlation between BMI and either cardiac, pulmonary or all complications. Ovenveight patients spent an average of 6.8 ± 0.4 days and 20.5 ± 5.3 days if they had a complication, which was 8.0 ± 3.0 days more than...

4733 Outcome of long term home enteral nutrition in patients with malignant dysphagia.

Background:Patients with a variety of malignancies may have severe dysphagia due to direct involvement of the gastrointestinal tract, the central nervous system, or as a result of antitumor therapies. In this setting enteral nutrition may be lifesaving and may be required for prolonged periods of time. Currently, neoplastic diseases account for approximately one-half of all patients receiving home enteral nutrition. Methods: A review of the records of all patients with malignant dysphagia who received home enteral nutrition for greater than 1 year was undertaken. For each patient the following factors were identified: age, primary cancer, type of enteral access, calories received, duration of therapy, complications, and need for tube replacement. Results: 82 patients were studied. Their mean age was 61 years (range 18-84). Primary cancers were as follows: head and neck 59 (71.9%), gastroesophageal 14 (17.0%), central nervous system 3 (3.6%), ovarian 2 (2.4%), and others 4 (4.9%). Enteral access devices used for long term feeding included percutaneous endoscopic gastrostomy tube (PEG) in 30 (36.6%) patients, low profile endoscopic button gastrostomy tube (PEGbutton) in 29 (35.3%) patients, percutaneous endoscopic jejunostomy tube (PEJ) in 9 (10.9%) patients, low profile endoscopic button jejunostomy tube (PEJ-button) in 6 (7.3%) patients, surgical jejunostomy tubes in 8 (8.7%) patients. On average, patients received 1978 cal/day (range: 500-3000) and were maintained on home enteral nutrition for 976 days (range: 367-3026). Complications at the tube site were: infection in 4 patients (4.8%), significant leakage in 2 patients (2.4%), and bleeding in 1 patient (1.2%). Metabolic and gastrointestinal complications were: 15 patients (18.2%) with diarrhea which required change of formula, 10 patients (12.2%) with constipation, 10 patients (12.2%) with hyperglycemia, and 1 patient (1.2%) with hyponatremia. Average lifespan of the enteral access devices was: PEG = 690 days, PEG button = 1701 days, PEJ = 591 days, PEJ button = 902 days, and surgical jejunostomy = 1114 days. Conclusions:Home enteral nutrition is a safe and effective means of long term nutritional support in patients with severe malignant dysphagia.

4737 Outcome of direct percutaneous endoscopic jejunostomy tube placement for nutritional support in critically-ill, mechanically ventilated patients.

Background: Gastrointestinal function is adversely affected in critically-ill, mechanically ventilated patients. The most common abnormality is delayed gastric emptying. This may lead to intolerance of gastric enteral feedings despite the presence of a functioning small bowel, and may predispose to aspiration pneumonia. Placement of a direct percutaneous endoscopic jejunostomy tube (PEJ) provides direct access to the small bowel and may therefore be the preferred route of access in critically-ill, mechanically ventilated patients who require enteral nutrition support. Methods:A review of the records of all patients who underwent direct PEJ tube placement while mechanically ventilated in the ICU was undertaken. For each patient the following factors were identified: age, indication for ICU admission and PEJ placement, nutritional support prior to and after PEJ placement, calories received, complications (aspiration, diarrhea, infection, bleeding, abdominal pain, leakage, or any procedural complications), and outcome. Results: 17 patients were studied. All had successful placement of direct PEJ tubes. The mean age was 64 years with a range of 25-83 years. Indications for PEJ placement included: aspiration pneumonia =9, intolerance of gastric enteral feedings =4, anastomotic leak after esophagectomy/gastric pull-up =3, duodenal obstruction =1. There was a single complication (colonic perforation). 15/17 patients tolerated jejunal feedings within 24 hours of PEJ placement. The mean daily caloric intake through the PEJ tube was 1994 cal (range 1440-2700) and all were able to progress to their established nutritional goals. There were no cases of aspiration of PEJ feeds. 13 patients required total parenteral nutrition (TPN) prior to PEJ placement. In all these patients TPN was not required once PEJ tubes were placed. 12 patients were discharged to home or a rehabilitation facility with jejunal feeds, 3 expired in the ICU, 1 was able to resume oral intake, and 1 remains hospitalized with continued enteral feedings. Conclusions: Direct PEJ is a safe and effective method to provide enteral nutrition support to critically-ill, mechanically ventilated patients who may not tolerate gastric enteral feeds and who might otherwise require TPN.