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

PURPOSE

Gastrointestinal function is adversely affected in critically ill mechanically ventilated patients. The most common abnormality is delayed gastric emptying. Among the options for postpyloric feeds, direct percutaneous endoscopic jejunostomy (PEJ) provides a permanent, reliable, and direct access to the small bowel and can be used for full enteral feedings, thus eliminating the need for parenteral nutrition.

PATIENTS AND METHODS

All patients who underwent direct PEJ tube placement while mechanically ventilated in the intensive care unit (ICU) were evaluated. For each patient the following factors were identified: age, indication for ICU admission and PEJ placement, nutritional support before and after PEJ placement, calories received, complications, and outcome.

RESULTS

Seventeen patients underwent the procedure. All had successful placement of direct PEJ tube. There was a single complication. Within 24 hours of PEJ placement, 16 of 17 patients tolerated jejunal feedings. All patients progressed to their established nutritional goals. There were no cases of aspiration of enteral feedings. In the 16 patients, total parenteral nutrition (TPN) was not required once PEJ tubes were placed. Thirteen patients were discharged home or to a rehabilitation facility with jejunal feedings.

CONCLUSIONS

Direct PEJ placement is a safe and reliable device that can be successfully placed in critically ill, mechanically ventilated patients. With this procedure, all patients can meet their nutritional requirements and eliminate the need for TPN.

Accuracy of predictions of survival at admission to the intensive care unit

PURPOSE

The purpose of this study was to compare the accuracy of outcome predictions made on the day of intensive care unit (ICU) admission by critical care physicians, critical care fellows, and primary team physicians.

PATIENTS AND METHODS

Fifty-nine consecutive patients admitted to a Medical-Surgical ICU were included in the study. Two ICU attending physicians and two critical care fellows, not involved in medical management, evaluated each new ICU patient at admission and after 48 to 72 hours. Altogether six ICU attendings and six fellows were involved in the study. Each investigator separately assigned probability to each patient of being discharged alive from the ICU and the hospital. On the day of admission the primary service was also asked to estimate the likelihood of successful outcome. All values are expressed in percentiles. Statistical analysis was performed by a logistic regression procedure with a binary outcome. Data are presented as mean +/- SD.

RESULTS

Fifty-nine patients were surveyed. Twenty-six (44%) patients died in the ICU, 3 (5%) died in the hospital wards, and 30 (51%) were discharged alive from the hospital. ICU attendings most reliably and accurately estimated patient outcome on admission compared with critical care fellows and primary team physicians. ICU attendings were more consistent than ICU fellows at predicting outcome at 48 and 72 hours. Clinical predictions were better for patients at the extremes of disease severity, and the accuracy of predictions in these patients was highest. Accuracy was diminished in patients with moderate compromise of clinical status.

CONCLUSION

ICU attendings predicted most accurately and consistently the final outcome of patients, and ICU fellows estimated outcome more reliably than the primary service. For the most part, the primary service tended to overestimate the probability of favorable outcome of patients for whom ICU admission had been requested. Additionally, clinical accuracy of survival or mortality was best for those patients at the extremes of clinical compromise: this point seems to confirm the validity of using clinical judgement as a guide to restricting ICU resources for those severely compromised or mildly compromised.This study also indicates that predictions of outcome in critically ill patients made within days of admission are statistically valid but not sufficiently reliable to justify irrevocable clinical decisions at present.

The effect of varying inspiratory flow waveforms on pulmonary mechanics in critically ill patients

PURPOSE

Ten mechanically ventilated patients were evaluated to determine the effect of three different inspiratory flow patterns on pulmonary mechanics.

MATERIALS AND METHODS

Ten consecutive mechanically ventilated critically ill patients with acute respiratory failure admitted to the intensive care unit were evaluated to assess the effects of decelerating, square, and sine waveforms on pulmonary mechanics. The variables measured were peak airway pressure (PaW), pleural pressure (Ppl), change in peak airway pressure (dPaW), inspiration time/total ventilation cycle time (Vi/tot), dynamic compliance (Cdyn), respiratory rate (RR), minute ventilation (Ve), and work of breathing (WOB).

RESULTS

The PaW, Ppl, and dPaW (cm H2O) were significantly lower using the decelerating inspiratory flow waveform (P<.05) compared with sine or square waveform patterns. Ti/Ttot was also lower with the decelerating waveform (P<.05) with better dynamic compliance compared with the other waveforms (P<.10).

CONCLUSIONS

These results indicate that critically ill mechanically ventilated patients show improved respiratory mechanics with decelerating inspiratory waveform that may have beneficial clinical implication.

Impact of involuntary outpatient commitment on the revolving-door syndrome in North Carolina

Involuntary outpatient commitment has been used as a means of treating so-called revolving-door patients in the community and allowing them to experience the positive aspects of social and community life that stability can bring. To study the impact of North Carolina's revised outpatient commitment law on institutionalization rates, the authors measured state hospital admissions and days of hospitalization within a three-year period for all patients committed to outpatient treatment during that period. Statistically significant decreases occurred in both measures; the biggest percent reduction occurred in admission rates.