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The traditional nasogastric/nasoenteric feeding tube is the preferred access device for short-term feeding (< 30 days), with delivery into the stomach suggested unless aspiration or motility abnormalities are present. Preference for a long-term access device is operator- and facility-dependent. Endoscopic or fluoroscopic placement is preferred as first choices over laparoscopic placement because of considerations of cost, need for general anesthesia, and need for operating room time. Gastrostomy is preferred over intestinal placement for long-term access unless problems with aspiration or motility abnormalities exist.

Critically ill patients invariably require nutritional intervention. Traditionally, enteral nutrition has not been widely employed in this patient population. This is due in part to the success of present-day parenteral nutrition, and to difficulties encountered with enteral feeding. Recent evidence has demonstrated that enteral is preferable to parenteral nutrition in terms of cost, complications, gut mucosal maintenance, and metabolic and immune function. Enterally administered nutritional support can and should be utilised as the preferred route of nourishment for the critically ill. The appropriate choice of access and formula, as well as a rational strategy for implementation, should improve the likelihood of success. This article describes the unique features of critical illness as they pertain to nutritional support, the benefits of enteral nutrition, and the obstacles to success, and offers suggestions which may improve the ability to provide nutrients adequately via the intestinal tract.

Tunneled polymeric silicone catheters and implantable infusion ports are used with increasing frequency. Complications may occur with catheter placement or ongoing use. A new technique is described that minimizes the risks associated with catheter reinsertion in patients with tunneled polymeric silicone catheters that are either malfunctioning or mispositioned. This procedure allows for the exchange of these catheters without incurring the risk of a new venipuncture.

In conflict, military medicine differs greatly from its civilian counterpart. Treatment strategies are designed to manage a potentially large number of severely wounded and function in an often hostile and poorly equipped environment. The most severely injured are stabilized and prepared for transport away from the war zone to a larger, better-equipped facility. At present no formal military policy exists concerning nutrition support. Traditionally, it has not been employed until the wounded arrived at a major medical center. Factors including the limited capacity to transport formula, lack of sophistication of battle zone facilities, and the rapid movement of wounded have been major drawbacks to providing early nutrition. The care of the urban trauma patient is relevant for the battle wounded of the military. There is ample evidence in the literature to support the use of nutrition support soon after injury. This article briefly describes the limitations of the military medical system in reference to nutrition support and the role of nutrition support for the civilian trauma patient. The lessons learned from the civilian experience may help formulate a nutrition strategy for the battle wounded that may become included into the standardized care policy.

Many centers advocate close patient follow-up and a multidisciplinary approach as necessary ingredients for the success of a bariatric surgery program. The military medical environment is not suitable for these conditions. Many patients are referred from great distances to the large regional medical centers, thereby preventing such close follow-up and the ability to create active support groups. A review of the 4-year experience with bariatric surgery at a major military medical center was conducted to determine if the program could be successful, considering that 60% of its patients came from out of state. Hospital records of all 92 patients and the bariatric registry were reviewed. A comprehensive survey to update weight data and assess patient satisfaction was sent to the first 72 patients to undergo surgery. There were no deaths and a perioperative complication rate of 18%. By I year after surgery, 67% of patients lost greater than 50% of their excess weight (mean = 56.6%). Sixty-eight percent of patients responded to the survey; 87% felt they were better off and satisfied with their quality of life since surgery, and 75% reported improved energy levels. If given a chance to rethink their decision, 86% of responders would choose surgery again. A total of 91% were satisfied with their follow-up. Patient proximity to the medical center did not influence weight loss or patient satisfaction. These results suggest that a bariatric surgery program can succeed in a medical environment such as the military where patients are likely to live at great distances from the hospital.

Objective: To compare the respiratory rate to tidal volume ratio with the oxygen cost of breathing to see which could more accurately predict the outcome of ventilator weaning for surgical patients., Design: Prospective comparison of two modalities used to predict the likelihood of successful ventilator weaning., Patients: Twenty-eight consecutive patients with chronic respiratory insufficiency requiring long-term mechanical ventilation in the surgical intensive care unit at New England Deaconess Hospital, Boston, Mass, were studied., Main Outcome Measures: The oxygen cost of breathing and the respiratory rate to tidal volume ratio were measured during spontaneous breathing. Patients extubated within 2 weeks of being studied were designated as extubated while patients not extubated within this period or requiring reintubation were recorded as not extubated., Results: The oxygen cost of breathing predicted successful extubation in all five patients who were extubated, and failure in 20 of 23 patients who could not be extubated (sensitivity, 100%; specificity, 87%). In contrast, the respiratory rate to tidal volume ratio predicted extubation for only two of five patients who were extubated and predicted failure in only 12 of 23 patients who could not be extubated (sensitivity, 40%; specificity, 52%)., Conclusion: For this group of patients requiring prolonged ventilation, the oxygen cost of breathing proved to be a more reliable predictor of both successful extubation and failure.

Pressure support ventilation (PSV) is a new ventilator modality that augments spontaneous inspiratory pressure with selected levels of positive airway pressure. There is presently considerable interest in its use in the management of critically ill, ventilator-dependent patients. The optimal method for application has not yet been established. This study investigated the effects of PSV on the oxygen cost of breathing (OCOB), a clinically applicable technique for quantitating the work of breathing. The OCOB and other bedside variables of pulmonary function were measured during PSV in ventilator-dependent patients where weaning was limited by an inability to sustain respiratory work. Nine studies were performed in 8 patients in the surgical intensive care unit. The OCOB, tidal volume (VT), respiratory rate (RR), and minute ventilation (VE) were measured at various levels of pressure support. The OCOB was calculated from the difference in oxygen consumption (VO2) during mechanical and spontaneous ventilation both at CPAP and with PSV. With increasing levels of PSV, the OCOB was observed to steadily decrease from 22% to 8% (p < 0.001). There were also statistically significant increases in VT and decreases in RR. VE appeared not to be influenced. The results of this study suggest that the bedside measurement of the OCOB may be an accurate, simple, and reproducible method of titrating the level of applied pressure support in order to optimize respiratory work.

A recent study demonstrated that the incidence of new arrhythmias occurring during central venous catheter insertion or exchange was 41% atrial and 25% ventricular arrhythmias (12% couplets or greater). Over-insertion of the guidewire, causing direct stimulation to the right side of the heart, has been postulated to be the causative factor. A new technique that allows the operator to control the length of guidewire inserted was developed. With this technique on a population of hospitalized patients, similar to those in the previous study, the incidence of atrial arrhythmias decreased to 32% and the incidence of ventricular arrhythmias to 6% (single premature ventricular contractions only). Although this new technique has limitations, there was a dramatic improvement in the incidence of cardiac arrhythmias. These results indicate a need for modifications in the available equipment to avoid the infrequent but life-threatening complication of malignant arrhythmia.

Obesity is associated with many comorbid disease states including neoplasia. The increased risk of developing endometrial cancer is thought to be due to the higher level of circulating estrogens in obese women. Uterine leiomyomata (fibroids) are also thought to be influenced by estrogens. To determine whether patients presenting with symptomatic uterine fibroids were more obese than the general population, we retrospectively reviewed the hospital records of 144 women who underwent either hysterectomy or myomectomy for uterine fibroids. Obesity was defined as preoperative weight greater than 120% of desirable body weight (DBW) for the patient's height. In our investigation, 51% of the study population were obese. Moreover, 16% were severely obese (defined as greater than 150% DBW). When compared with the general population of women in the United States matched for height and age, the study population was significantly heavier. (p less than 0.0002). Patient age, parity, menopausal status, and degree of obesity did not correlate with the number of fibroids within the uterus. Fibroid size was significantly larger in nulliparous women (p less than 0.005). These results suggest that symptomatic uterine fibroids may be another comorbid disease state associated with obesity.

Advances in major gastrointestinal surgery and the existence of a significant number of high-risk patients necessitate a detailed knowledge of the metabolic response to surgery and the need for adjunctive nutritional therapy. Such surgery has the potential to cause significant nutritional consequences affecting patient outcome. Often, patients present malnourished preoperatively because of their chronic gastrointestinal disease, advanced age, or comorbidity. Still others are at great risk for developing malnutrition postoperatively secondary to the hypercatabolism of prolonged illness or postoperative complications. In addition, the surgical alterations of the gastrointestinal tract might disrupt normal function sufficiently to result in chronic nutritional deficiencies. Because starvation is no longer an acceptable condition, these concerns need to be recognized prior to surgery, and if indicated, nutritional support must be initiated preoperatively. Placement of feeding jejunostomy catheters for early enteral support should be considered for all high-risk patients. Equally important, surgeons should maintain a watch for future nutritional innovations that will improve their ability to meet patients' nutritional requirements.

A 75-year-old patient with anuric renal failure developed a significant metabolic alkalosis thought to be due to the enteral absorption of "nonsystemic" antacid administered in large daily doses for prevention of recurrent peptic ulcer disease.

The risk of complication during the insertion or exchange of central venous catheters has been well documented. The majority of complications involve mechanical problems associated with insertion. Although cardiac arrhythmia has been acknowledged as a possible complication, its incidence has never been quantified. We performed cardiac monitoring on patients during 51 central venous catheter insertions or exchanges to determine the incidence of cardiac arrhythmias during guidewire insertion. Forty-one percent of procedures resulted in atrial arrhythmias and 25% produced some degree of ventricular ectopy, 30% of these were ventricular couplets or greater. Ventricular ectopy was significantly more common in shorter patients (160 +/- 8 vs 168 +/- 11 cm, p less than 0.05) and when the catheter was inserted from the right subclavian position (43% ventricular ectopy vs 10% at the other sites). Other variables such as age, cardiac history, serum potassium, type of procedure, and catheter brand were not significant. It is our conclusion that over-insertion of the wire causes this cardiac stimulation. Despite the absence of morbidity or mortality in this study, this incidence of ventricular ectopy indicates that there is a distinct possibility of a malignant arrhythmia being precipitated by a guidewire. Some modification of the current protocol for these procedures seems indicated.

During the course of a critical illness, many patients become ventilator dependent. The standard assessment criteria are not always accurate in predicting potential for extubation. This investigation was designed to analyze whether the work of breathing (WOB) was a more reliable predictor of ventilator dependence. Twenty consecutive ventilator-dependent patients were prospectively studied. Nineteen required ventilator support for greater than 2 wk and all were considered ventilator dependent because of their inability to tolerate weaning trials. The oxygen consumption (VO2) and resting energy expenditure were measured using a metabolic gas monitor. Respiratory mechanics and arterial blood gas measurements were obtained, and the deadspace to tidal volume ratio (VD/VT) was calculated. The WOB was determined by the difference in VO2 between spontaneous and mechanical ventilation, and expressed as a percentage of VO2 during mechanical ventilation. Five of eight patients with a WOB less than 15% (mean 1.9) were extubated within 2 wk of study, while none of 12 patients with a WOB greater than or equal to 15% (mean 34) were able to be extubated in this period. The differences in the WOB between the two groups were statistically significant (p less than .01), while there was no significant difference in mechanics, PaCO2, VD/VT or measured resting energy expenditure. These data support the use of WOB determinations in evaluating extubation potential. Using a reference value for the WOB of 15%, this study had a sensitivity of 100% and a specificity of 80%. This proved to be of greater predictive value than traditional criteria.