Safety of minimizing preoperative starvation in critically ill and intubated trauma patients

Nutritional support for the trauma and emergency general surgery patient: What you need to know

ABSTRACT

Decades of research have provided insight into the benefits of nutritional optimization in the elective surgical patient. Patients who are nutritionally prepared for surgery enjoy reduced length of hospital and intensive care unit stays and suffer fewer complications. In the trauma and emergency general surgery patient populations, we are not afforded the preoperative period of optimization and patients often suffer longer lengths of hospital stay, discharge to nonhome destinations, and higher infectious and mortality rates. Nonetheless, ongoing research in this vulnerable and time critical diagnosis population has revealed significant outcomes benefits with the meticulous nutritional support of these patients. However, it is important to note that optimal nutritional support in this challenging patient population is not simply a matter of "feeding more and feeding earlier." In this review, we will address assessing nutritional needs, the provision of optimal nutrition, the timing and route of nutrition, and monitoring outcomes and discuss the management of nutrition in the complex trauma and emergency general surgery patient.

LEVEL OF EVIDENCE

Literature Synthesis and Expert Opinion; Level V.

Nutritional Support in Critically Ill Trauma Patients

Enteral nutrition should be initiated within 24 to 48 hours of injury, starting at a trophic rate and increasing to goal rate after hemodynamic stability is achieved. The modified Nutritional Risk in the Critically Ill score can help identify patients who will benefit most from aggressive and early nutritional intervention. In the first week of critical illness, the patient should receive only 70% to 80% of estimated calories and protein should be targeted to 1.5 to 2 g/kg. Parenteral nutrition can be provided safely without increased adverse events. Peri-operative (and intra-operative) feeding has been shown to be safe in selected patients.

Preprocedural fasting policies for patients receiving tube feeding: A national survey

BACKGROUND

Patients who are critically ill frequently accrue substantial nutrition deficits due to multiple episodes of prolonged fasting prior to procedures. Existing literature suggests that, for most patients receiving tube feeding, the aspiration risk is low. Yet, national and international guidelines do not address fasting times for tube feeding, promoting uncertainty regarding optimal preprocedural fasting practice. We aimed to characterize current institutional fasting practices in the United States for patients with and without a secure airway, with variable types of enteral access, for representative surgical procedures.

METHODS

The survey was distributed to a purposive sample of academic institutions in the United States. Reponses were reported as restrictive (6-8 h preprocedurally) or permissive (<6 h or continued intraprocedurally) feeding policies. Differences between level 1 trauma centers and others, and between burn centers and others, were evaluated.

RESULTS

The response rate was 40.3% (56 of 139 institutions). Responses revealed a wide variability with respect to current practices, with more permissive policies reported in patients with secure airways. In patients with a secure airway, Level 1 trauma centers were significantly more likely to have permissive fasting policies for patients undergoing an extremity incision and drainage for each type of feeding tube surveyed.

CONCLUSIONS

Current hospital policies for preprocedural fasting in patients receiving tube feeds are conflicting and are frequently more permissive than guidelines for healthy patients receiving oral nutrition. Prospective research is needed to establish the safety and clinical effects of various fasting practices in tube-fed patients.

The open abdomen in trauma, acute care, and vascular and endovascular surgery: comprehensive, expert, narrative review

BACKGROUND

The open abdomen is an innovation that greatly improved surgical understanding of damage control, temporary abdominal closure, staged abdominal reconstruction, viscera and enteric fistula care, and abdominal wall reconstruction. This article provides an evidence-informed, expert, comprehensive narrative review of the open abdomen in trauma, acute care, and vascular and endovascular surgery.

METHODS

A group of 12 international trauma, acute care, and vascular and endovascular surgery experts were invited to review current literature and important concepts surrounding the open abdomen.

RESULTS

The open abdomen may be classified using validated systems developed by a working group in 2009 and modified by the World Society of the Abdominal Compartment Syndrome-The Abdominal Compartment Society in 2013. It may be indicated in major trauma, intra-abdominal sepsis, vascular surgical emergencies, and severe acute pancreatitis; to facilitate second look laparotomy or avoid or treat abdominal compartment syndrome; and when the abdominal wall cannot be safely closed. Temporary abdominal closure and staged abdominal reconstruction methods include a mesh/sheet, transabdominal wall dynamic fascial traction, negative pressure wound therapy, and hybrid negative pressure wound therapy and dynamic fascial traction. This last method likely has the highest primary fascial closure rates. Direct peritoneal resuscitation is currently an experimental strategy developed to improve primary fascial closure rates and reduce complications in those with an open abdomen. Primary fascial closure rates may be improved by early return to the operating room; limiting use of crystalloid fluids during the surgical interval; and preventing and/or treating intra-abdominal hypertension, enteric fistulae, and intra-abdominal collections after surgery. The majority of failures of primary fascial closure and enteroatmospheric fistula formation may be prevented using effective temporary abdominal closure techniques, providing appropriate resuscitation fluids and nutritional support, and closing the abdomen as early as possible.

CONCLUSION

Subsequent stages of the innovation of the open abdomen will likely involve the design and conduct of prospective studies to evaluate appropriate indications for its use and effectiveness and safety of the above components of open abdomen management.

Should adult ventilated patients on the intensive care unit be fasted preoperatively?

In the absence of separate guidelines for critically unwell ventilated patients in the intensive care unit who are undergoing surgery, questions arise about whether patients in intensive care should be starved preoperatively, despite already having a protected airway.

Critical Care Considerations for Damage Control in a Trauma Patient

Traumatic injury remains the leading cause of death among individuals younger than age 45 years. Hemorrhage is the primary preventable cause of death in trauma patients. Management of hemorrhage focuses on rapidly controlling bleeding and addressing the lethal triad of hypothermia, acidosis, and coagulopathy. The principles of damage control surgery are rapid control of hemorrhage, temporary control of contamination, resuscitation in the intensive care unit to restore normal physiology, and a planned, delayed definitive operative procedure. Damage control resuscitation focuses on 3 key components: fluid restriction, permissive hypotension, and fixed-ratio transfusion. Rapid recognition and control of hemorrhage and implementation of resuscitation strategies to control damage have significantly improved mortality and morbidity rates. In addition to describing the basic principles of damage control surgery and damage control resuscitation, this article explains specific management considerations for and potential complications in patients undergoing damage control interventions in an intensive care unit.

Application of the modified Nutrition Risk in Critically Ill score to nutritional risk stratification of trauma victims: A multicenter observational study

BACKGROUND

The modified Nutrition Risk in Critically Ill (mNUTRIC) score was developed to identify patients most likely to benefit from nutritional therapies and to stratify or select study subjects for clinical trials. The score is not validated in trauma victims in whom adequate nutritional support is important and difficult to achieve. We sought to determine whether a higher mNUTRIC score was associated with worse outcomes and whether caloric and protein intake improved outcome more in patients classified as high risk relative to those classified as low risk.

METHODS

We analyzed a prospectively collected database of patients from intensive care units globally. The primary outcome was 60-day hospital mortality, and the secondary outcome was time to discharge alive. We compared outcomes between high and low mNUTRIC score groups and also tested whether the association between outcome and nutrition intake was modified by the mNUTRIC score.

RESULTS

A total of 771 trauma patients were included. Most (585; 76%) had a low-risk mNUTRIC (0-4) score, and 186 (24%) had a high-risk (5-9) mNUTRIC score. The overall 60-day mortality was 13%. Patients in the high mNUTRIC group had a higher risk of death than those in the low mNUTRIC group (adjusted odds ratio, 2.6; 95% confidence interval, 1.7-4.2). Overall, there was no relationship between caloric or protein intake and clinical outcomes. However, patients in the high mNUTRIC group fared better with increasing caloric and protein intake, whereas subjects in the low mNUTRIC score group did not (p values for interaction with the mNUTRIC score for time to discharge alive was p = 0.014 for calories and was p = 0.004 for protein).

CONCLUSION

A high mNUTRIC score identifies trauma patients at higher risk for poor outcomes and those who may benefit from higher caloric and protein intake.

LEVEL OF EVIDENCE

Epidemiological/Prognostic, level III.

Impact of enteral nutrition interruptions on underfeeding in intensive care unit

BACKGROUND & AIMS

Malnutrition leads to poor outcomes for critically ill patients; however, underfeeding remains a prevalent issue in the intensive care unit (ICU). One of the reasons for underfeeding is enteral nutrition interruption (ENI). Our aim was to investigate the causes, frequency, and duration of ENIs and their association with underfeeding in critical care.

METHODS

This was a prospective observational study conducted at the Vilnius University Hospital Santaros Clinics, Lithuania, between December 2017 and February 2018. It included adult medical and surgical ICU patients who received enteral nutrition (EN). Data on ENIs and caloric, as well as protein intake were collected during the entire ICU stay. Nutritional goals were assessed using indirect calorimetry, where available.

RESULTS

In total 73 patients were enrolled in the study. Data from 1023 trial days and 131 ENI episodes were collected; 68% of the patients experienced ENI during the ICU stay, and EN was interrupted during 35% of the trial days. The main reasons for ENIs were haemodynamic instability (20%), high gastric residual volume (GRV) (17%), tracheostomy (16%), or other surgical interventions (16%). The median duration of ENI was 12 [6-24] h, and the longest ENIs were due to patient-related factors (22 [12-42] h). The rate of underfeeding was 54% vs. 15% in the trial days with and without ENI (p < 0.001), respectively. Feeding goal was achieved in 26% of the days with ENI vs. 45% of days without ENI (p < 0.001). The daily average caloric provision was 77 ± 36% vs. 106 ± 29% in the trial days with and without ENI (p < 0.001) and protein provision was 0.96 ± 0.5 vs. 1.3 ± 0.5 g/kg, respectively (p < 0.001).

CONCLUSIONS

The episodes of ENI in critically ill patients are frequent and prolonged, often leading to underfeeding. Similar observations have been reported by other studies; however, the causes and duration of ENI vary, mainly because of different practices worldwide. Hence, safe and internationally recognised reduced-fasting guidelines and protocols for critically ill patients are needed in order to minimise ENI-related underfeeding and malnutrition.

Early Achievement of Enteral Nutrition Protein Goals by Intensive Care Unit Day 4 is Associated With Fewer Complications in Critically Injured Adults

: Objective: We hypothesized that failure to achieve protein goals early in the critical care course via enteral nutrition is associated with increased complications.

BACKGROUND

Although robust randomized controlled trials are lacking, present data suggest that early, adequate nutrition is associated with improved outcomes in critically ill patients. Injured patients are at risk of accumulating significant protein debt due to interrupted feedings and intolerance.

METHODS

Critically injured adults who were unable to be volitionally fed were included in this retrospective review. Data collected included demographics, injury characteristics, number and types of operations, total prescribed and delivered protein and calories during the first 7 days of critical care admission, complications, and outcomes. Group-based trajectory modeling was applied to identify subgroups with similar feeding trajectories in the cohort.

RESULTS

There were 274 patients included (71.2% male). Mean age was 50.56  ± 19.76 years. Group-based trajectory modeling revealed 5 Groups with varying trajectories of protein goal achievement. Group 5 fails to achieve protein goals, includes more patients with digestive tract injuries (33%, P = 0.0002), and the highest mean number of complications (1.52, P = 0.0086). Group 2, who achieves protein goals within 4 days, has the lowest mean number of complications (0.62, P = 0.0086) and operations (0.74, P = 0.001).

CONCLUSIONS

There is heterogeneity in the trajectory of protein goal achievement among various injury pattern Groups. There is a sharp decline in complication rates when protein goals are reached within 4 days of critical care admission, calling into question the application of current guidelines to healthy trauma patients to tolerate up to 7 days of nil per os status and further reinforcing recommendations for early enteral nutrition when feasible.

Increasing Enteral Protein Intake in Critically Ill Trauma and Surgical Patients

BACKGROUND

Published guidelines recommend providing at least 2 g/kg/d of protein for critically ill surgical patients. It may be difficult to achieve this level of intake using standard enteral formulas, thus necessitating protein or amino acid supplementation. Herein, we report our approach to enteral protein supplementation and its relationship with urinary nitrogen excretion and serum transthyretin concentrations.

METHODS

This was a retrospective cohort study in which we reviewed critically ill trauma and surgical patients treated with supplemental enteral protein according to a protocol aiming to deliver a total of 2 g/kg/d of protein. We collected detailed nutrition data over a 2-week period after admission and obtained additional data through discharge to determine caloric and protein intake as well as complications. We also compared urine nitrogen excretion and transthyretin concentrations between these patients and a control group who did not receive supplemental protein.

RESULTS

Fifty-three subjects received early protein supplementation. Formula and protein supplement each provided ≈1.2 g/kg/d of protein by intensive care unit day 4. This resulted in a median total protein intake of 2.2 g/kg/d through day 14. One patient developed acute kidney injury, and 1 patient had 3 episodes of vomiting. By the third week, serum transthyretin concentrations increased to a median of 21 mg/dL compared with 13 mg/dL in subjects not receiving early supplementation.

CONCLUSION

It is safe to deliver supplemental protein enterally to critically ill surgical and trauma patients and reach 2 g/kg/d of protein intake during the first week of illness.

New Protocol Avoiding Tube Feed Interruptions in Critically Ill Patients Requiring Tracheostomy

Current anesthesia guidelines require tube feed (TF) interruption for at least four hours before tracheostomy. We hypothesized that preprocedural TF interruption is not required before tracheostomy. We developed a protocol allowing continued feeding. Fifty-six patients undergoing tracheostomy with or without percutaneous endoscopic gastrostomy placement were included. Eleven patients underwent tracheostomy without TF interruption (TF group); the remaining 45 patients had TFs held per the existing anesthesia protocol (nil per os group). Data were collected by retrospective chart review. The groups were similar with regard to age, sex, race, risk of mortality, and preoperative albumin levels (3.2 vs 2.9 g/dL). There was no difference in pulmonary complications. No intraoperative aspiration occurred in either group, and there was no increase in mortality in the TF group (9.1 vs 22.2%, P = 0.43). The TF group had feeds held for 9.5 ± 6.3 vs 25.4 ± 19.0 hours (P = 0.0018). The TF group had a decreased missed caloric intake [761.5 ± 566.6 vs 1983.5 ± 1590.8 kcal (P = 0.0039)]. The TF group had a shorter time from consultation [40.4 vs 50.6 hours (P = 0.54)] and case booking [7.9 vs 12.8 hours (P = 0.40)] to the OR. The average length of stay for the TF group was 26.3 versus 31.1 days (P = 0.45). There was no increase in pulmonary complications or mortality in the fed patients, who experienced less procedural delays. Meanwhile, patients kept nil per os sustained a substantial caloric deficit. Tracheostomy without TF interruption is feasible and reduces malnutrition.

The open abdomen in trauma and non-trauma patients: WSES guidelines

Damage control resuscitation may lead to postoperative intra-abdominal hypertension or abdominal compartment syndrome. These conditions may result in a vicious, self-perpetuating cycle leading to severe physiologic derangements and multiorgan failure unless interrupted by abdominal (surgical or other) decompression. Further, in some clinical situations, the abdomen cannot be closed due to the visceral edema, the inability to control the compelling source of infection or the necessity to re-explore (as a "planned second-look" laparotomy) or complete previously initiated damage control procedures or in cases of abdominal wall disruption. The open abdomen in trauma and non-trauma patients has been proposed to be effective in preventing or treating deranged physiology in patients with severe injuries or critical illness when no other perceived options exist. Its use, however, remains controversial as it is resource consuming and represents a non-anatomic situation with the potential for severe adverse effects. Its use, therefore, should only be considered in patients who would most benefit from it. Abdominal fascia-to-fascia closure should be done as soon as the patient can physiologically tolerate it. All precautions to minimize complications should be implemented.

Biochemical Markers of Nutrition Support in Critically Ill Trauma Victims

BACKGROUND

In critically ill patients, plasma serum albumin and transthyretin concentrations are thought to reflect the effects of acute illness, including resuscitation and inflammation. Their use as markers for preexisting nutrition status is, therefore, not recommended. Whether they can be used to assess subsequent effectiveness of artificial nutrition support is unclear. We sought to determine if these biomarkers are associated with enteral caloric intake in critically ill trauma patients.

MATERIALS AND METHODS

We analyzed data from adult trauma victims who required ≥2 days of mechanical ventilation and ≥7 days of intensive care. We categorized patients into low, middle, or high enteral calorie delivery groups (2, 9, or 17 kcal/kg/d during the first week). We compared serial concentrations of serum albumin, transthyretin, and C-reactive protein. Multiple linear and Poisson regression were used to determine relationships between calorie intake and nutrition biomarkers.

RESULTS

In total, 1056 patients were analyzed. Their median age was 44 (interquartile range [IQR], 28-57) years, and median injury severity score was 34 (IQR, 26-41). Calorie intake during the first week was not related to biomarkers during the first or second week. However, by the beginning of the third week, the highest calorie group showed greater changes in concentrations of transthyretin (+3.0 mg/dL relative to initial concentration, P = .01) and serum albumin (+0.17 g/dL, P = .05) compared with the lowest calorie group.

CONCLUSIONS

In trauma patients requiring 1 or more weeks of intensive care, changes in transthyretin were associated with enteral caloric intake. Our data suggest that transthyretin could be used to monitor nutrition support after 2 weeks in intensive care.

Exploring fasting practices for critical care patients - A web-based survey of UK intensive care units

Background

Enteral nutrition delivery in the critically ill is frequently interrupted for surgical and airway procedures to avoid aspiration of stomach contents. Recurrent fasting leads to under delivery of enteral nutrition and this underfeeding is associated with worse outcomes. International fasting recommendations do not provide guidance for intubated patients receiving enteral nutrition. This study aimed to gain a detailed perspective of UK critical care fasting practices.

Methods

A web-based survey was sent to 232 UK intensive care units consisting of questions relating to fasting practices, presence of guidelines, average fasting times for common procedures and dietitian time per intensive care unit bed.

Results

A total of 176 intensive care units responded. Only 20% of units had guidelines and respondents stated that they were not consistently adhered to (mean compliance 66%). Units with greater dietetic involvement were more likely to have guidelines (p = 0.04). Fasting times were shorter for abdominal surgery (p = 0.002), non-abdominal surgery (p = 0.016) and radiology (p = 0.015) if a guideline was present. Fasting for extubation and tracheostomy was similar irrespective of the presence of a guideline. Considerable variation in fasting times was reported, usually due to inconsistencies in clinical decision-making.

Conclusions

This survey of national practice demonstrates that fasting times are varied and inconsistent, which may lead to under-delivery of enteral nutrition. More dietetic input was associated with increased likelihood of a fasting guideline.

Strategies for the Enhancement of Nutrition Practice in a New York State Level 1 Trauma Center: A Hospital's Journey

BACKGROUND

Provision of enteral nutrition (EN) support is historically inadequate in the critically ill population. An interdisciplinary approach utilizing various strategies has been shown to improve initiation of timely EN support. The purpose of this study was to examine whether the implementation of a series of interventions led by an interdisciplinary team was associated with changes in the initiation of nutrition support in a level 1 trauma center.

METHODS

Patients admitted between 2009 and 2013 with isolated closed head trauma injuries were identified through the hospital's trauma center database. The initial population consisted of 159 patients; after exclusion criteria, 141 patients were included in the statistical analyses. Two statistical analyses were conducted. The first calculated the average days to the initiation of nutrition start by admission year. The second estimated the association between admission year and time to nutrition initiation with a generalized linear model.

RESULTS

Time to initiate nutrition therapy was estimated to decrease by 1.46 days (47.31%) from 2009 to 2013. The time to initiate nutrition in 2013 was 1.63 days. A significant association was found between the time to initiate nutrition and the 2012 and 2013 binary variables while controlling for confounding variables. The time frame was estimated to be 1.09 (P = .008) and 1.75 (P = .000) days shorter in 2012 and 2013 relative to 2009.

CONCLUSIONS

An interdisciplinary effort utilizing multiple strategies identified and addressed barriers, resulting in a reduction of variability and a proactive approach to early EN.