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Summary Introduction Predigested, peptide-based enteral formulas are commonly used to promote GI tolerance in critically ill patients, but studies comparing these against polymeric enteral formulas are lacking. We performed a prospective, randomized clinical comparison pilot study to assess safety, tolerance and effectiveness of a peptide-based enteral product. Methods Critically ill patients from ICUs, including medical, surgical, and cardiothoracic, were randomized to either of two enteral feeding products: Group A: Peptide-based, high Protein, high omega-3 fat (Vital AF ® , Abbott Nutrition); Group B: high protein standard enteral formula (Osmolite ® , Abbott Nutrition). Tolerance and comorbidities as well as enteral feeding volume were collected at baseline and then daily for up to 21 days, or until the patient was discharged from the ICU. Results A total of 49 patients were included, 25 (51%) on group A, 24 (49%) on group B. Adverse events and undesired gastrointestinal events at baseline and mean intake (ml/d and percent of goal) post baseline were not different between the groups. There were significantly fewer days with adverse events (p = 0.0336, odds ratio = 3.02, standard error = 1.60, n = 24 per group) and undesired gastrointestinal events (p = 0.0489, odds ratio = 2.79, standard error = 1.48, n = 24 per group) in group A. There was no difference in other clinical outcomes. Conclusion This pilot study suggests that feeding a peptide-based formula to ICU patients may be associated with a statistically significant reduction in the number of days during which adverse events occurred as compared to a standard formula.

Functional and structural liver abnormalities may be found in patients with advanced heart failure (HF). The Model of End-Stage Liver Disease Excluding INR (MELD-XI) score allows functional risk stratification of HF patients on and off anti-coagulation awaiting heart transplantation (HTx), but these scores may improve or worsen depending on bridging therapies and during time on the waiting list. Liver biopsy is sometimes performed to assess for severity of fibrosis. Uncertainty remains whether biopsy in addition to MELD-XI improves prediction of adverse outcomes in patients evaluated for HTx.Sixty-eight patients suspected of advanced liver disease underwent liver biopsy as part of their HTx evaluation. A liver risk score (fibrosis-on-biopsy + 1) × MELD-XI was generated for each patient.Fifty-two patients were listed, of whom 14 had mechanical circulatory support (MCS). Thirty-six patients underwent transplantation and 27 patients survived ≥1 year post-HTx (74%, as compared with 88% average 1-year survival in HTx patients without suspected liver disease; p0.01). Survivors had a lower liver risk score at evaluation for HTx (31.0 ± 20.4 vs 65.2 ± 28.6, p0.01). A cut-point of 45 for liver risk score was identified by receiver-operating-characteristic (ROC) analysis. In the analysis using Cox proportional hazards models, a liver risk score ≥45 at evaluation for HTx was associated with greater risk of death at 1 year post-HTx compared with a score of45 in both univariable (HR 3.94, 95% CI 1.77-8.79, p0.001) and multivariable (HR 4.35, 95% CI 1.77-8.79, p0.001) analyses. Patients who died1 year post-HTx had an increased frequency of acute graft dysfunction (44.4% vs 3.7%, p = 0.009), longer ventilation times (55.6% vs 11.1%, p = 0.013) and severe bleeding events (44.4% vs 11.1%, p = 0.049). The liver risk score at evaluation for HTx also predicted 1-year mortality after HTx listing (p0.001).Patients with HF and advanced liver dysfunction are high-risk HTx candidates. Liver biopsy in addition to MELD-XI improves risk stratification of patients with advanced HF and suspected irreversible liver dysfunction.

Parenteral nutrition is associated with increased central line-associated bloodstream infections (CLABSIs). Electronic databases are important for identifying independent risk factors for prevention strategies. Our aims were to evaluate the utility of using electronic data sources to identify risk factors for CLABSIs, including parenteral nutrition (PN), and to assess the association between CLABSI and PN administration.Data were obtained for all discharges of adult patients in whom a central line was inserted between September 1, 2007, and December 31, 2008, in a large, academically affiliated hospital in New York City. CLABSI was defined electronically using a modified definition from the Centers for Disease Control and Prevention. A manual chart review was also undertaken to assess validity/reliability of the electronic database and gather additional information. Risk factors for CLABSI were examined using logistic regression.Among 4840 patients, there were 220 CLABSIs, an incidence of 5.4 CLABSIs per 1000 central line days. Risk factors included PN (odds ratio [OR], 4.33; 95% confidence interval [CI], 2.50-7.48), intensive care unit stay (OR, 2.26; 95% CI, 1.58-3.23), renal disease (OR, 2.79; 95% CI, 2.00-3.88), and immunodeficiency (OR, 2.26; 95% CI, 1.70-3.00). Diabetes mellitus was associated with reduced CLABSI rates (OR, 0.63; 95% CI, 0.45-0.88).The utility of electronic medical records for determining risk factors is limited by such things as free-text data entry. Using a hybrid between fully electronic and manual chart review, reliable data were obtained. PN is associated with a high risk for CLABSI in a population highly selected for indications for PN.

procedural attempts at DPEJ, procedure duration, technical success rate, causes for failed DBE-DPEJ placement, and adverse events. Results: A total of 90 patients (55 women; mean age 55 18 years; mean BMI 22.9 6.3) underwent DBE-DPEJ placement (Table 1). Indications for DPEJ included: gastroparesis (nZ29), previous failed PEG (e.g., intrathoracic stomach, nZ16), nutritional support in altered gut anatomy unsuitable for PEG (nZ16), recurrent or high risk for aspiration (nZ13), gastric outlet obstruction (nZ11), and miscellaneous (e.g., nutritional support in setting of necrotizing pancreatitis, nZ5). Altered gut anatomy was noted in 35 (39%) patients. DBE-DPEJ was successful in all patients (nZ12) who had prior failed DPEJ attempts by extended push endoscopy or single balloon endoscopy. Mean duration of the DBE-DPEJ procedure was 31 minutes (range 10-49). DBE-DPEJ placement was successful in 83 (92%) patients. Reasons for failed DBE-DPEJ placement in 7 (8%) patients included: small bowel fixation from adhesions precluding endoscope advancement (nZ5), duodenal stenosis (nZ1), and lack of transillumination (nZ1). Post-procedural adverse events occurred in 8 (9%) patients and included: gastrointestinal bleed secondary to DPEJ site ulceration (nZ3), abdominal hematoma (nZ2), cellulitis (nZ1), kinking of the PEJ tube requiring replacement (nZ1) and gastric interposition (nZ1). Conclusion: Compared to published outcomes of DPEJ placement by conventional endoscopy, DBE-assisted DPEJ was technically successful in a high proportion of patients and with a relatively low rate of significant adverse events.