Surgical palliative care training in general surgery residency: An educational needs assessment.

INTRODUCTION: There is increasing recognition that Surgical Palliative Care is an essential component of the holistic care of surgical patients and involves more than end-of-life care in the intensive care unit. General surgery residents are clinically exposed to patients with palliative care needs during each year of training, but few have a dedicated surgical palliative care curriculum. We undertook this educational needs assessment as the first step towards a longitudinal curriculum. METHODS: We conducted an anonymous survey of 94 general surgery residents and 115 faculty at community and university hospitals to assess their experience and comfort with surgical palliative care delivery. Residents and faculty were asked multiple choice and open-ended questions. RESULTS: There was a 55% response rate from residents and 33% response rate from faculty. The majority (77%) of respondents were junior residents (PGY1-3) and university-based faculty (66%). Approximately half of residents felt comfortable leading conversations in goals of care (58%), comfort-focused care (52%) and delivering bad news (57%), while greater than 90% of faculty agreed that chief residents needed additional training. All residents agreed they needed additional training and 85% wanted a formal curriculum. Analysis of open-ended questions suggests a deficiency in the pre-operative setting as no residents had participated in these conversations in an outpatient setting. CONCLUSION: Residents and faculty believe trainees would benefit from further education in surgical palliative care with a dedicated curriculum. The outpatient, pre-operative counseling of patients was identified as a key learning need. These data support our ongoing work to develop a surgically pertinent palliative care curriculum.

In Search of the Ideal Promotility Agent: Optimal Use of Currently Available Promotility Agents for Nutrition Therapy of the Critically Ill Patient.

PURPOSE OF REVIEW: Enteral nutrition therapy is essential in the management of critically ill patients. Prokinetic agents have been used successfully to aid in the delivery of nutrition and improve feeding tolerance in patients in the intensive care unit (ICU). The aim of this report is to review the existing promotility agents available for use in the critically ill as well as outline the role of potential investigative drugs in order to provide a guide to the management of this difficult and important clinical dilemma. RECENT FINDINGS: While no single currently available agent currently meets all of the desired goals in the critical care setting, there are an increasing number of available agents from which to choose including motilin receptor agonists, 5HT4 receptor agonists, D2 receptor antagonists, and Mu opioid receptor antagonists. We recommend a multifaceted approach to optimizing enteral nutrition in the critical care setting which should include the early, prophylactic use of promotility agents and should focus on the management of reversible causes of impaired gastrointestinal motility.

Parenteral or Enteral Arginine Supplementation Safety and Efficacy.

Arginine supplementation has the potential to improve the health of patients. Its use in hospitalized patients has been a controversial topic in the nutrition literature, especially concerning supplementation of septic patients. In this article, we review the relevant literature both for and against the use of arginine in critically ill, surgical, and hospitalized patients. The effect of critical illness on arginine metabolism is reviewed, as is its use in septic and critically ill patients. Although mounting evidence supports immunonutrition, there are only a few studies that suggest that this is safe in patients with severe sepsis. The use of arginine has been shown to benefit a variety of critically ill patients. It should be considered for inclusion in combinations of immunonutrients or commercial formulations for groups in whom its benefit has been reported consistently, such as those who have suffered trauma and those in acute surgical settings. The aims of this review are to discuss the role of arginine in health, the controversy surrounding arginine supplementation of septic patients, and the use of arginine in critically ill patients.

Nutritional Therapy for Critically Ill Patients.

Nutrition therapy provided early in the critical care setting has been shown to improve outcome. Appropriate and early nutrition interventions can attenuate the hyperdynamic systemic response and depressed immune reaction to injury, serious illness and major surgery. Controversies limit the uniform application and potential benefits of nutrition, including failure to accurately predict who will 'need' nutritional intervention, lack of consensus on what the optimal enteral formulation is, overreliance on parenteral nutrition, failure to maximize the use of early enteral nutrition (EN), and how much and how best to feed the morbidly obese population. Despite challenges and inconsistencies in today's critical care setting, specialized nutrition has evolved from metabolic 'support' during critical illness to a primary therapeutic intervention designed, individualized and focused to achieve metabolic optimization and mitigation of stress-induced immune and hyperdynamic systemic responses. Nutrition should be considered early and commenced after initial resuscitation has taken place. This is most effectively accomplished with the use of protocols that aggressively promote early EN, and will result in lower mortality and a reduction in major complications. Though the complexity of the heterogeneous critically ill population will always be challenging, we are developing a better understanding of immunity, metabolic needs and catabolism associated with intensive care unit admissions.

Nutrition optimization prior to surgery.

Optimization of metabolic state prior to major surgery leads to improved surgical outcomes. Nutrition screening protocols should be implemented in the preoperative evaluation, possibly as part of a bundle. Strategies to minimize hyperglycemia and insulin resistance by aggressive preoperative nutrition and carbohydrate loading may promote maintenance of a perioperative anabolic state, improving healing, reducing complications, and shortening the time to recovery of bowel function and hospital discharge. Short courses of preoperative immune-modulating formulas, using combinations of arginine, ω-3 fatty acids, and other nutrients, have been associated with improved surgical outcomes. These immune-modulating nutrients are key elements of metabolic pathways that promote attenuation of the metabolic response to stress and improve both wound healing and immune function. Patients with severe malnutrition and gastrointestinal dysfunction may benefit from preoperative parenteral nutrition. Continuation of feeding through the intraoperative period for severely stressed hypermetabolic patients undergoing nongastrointestinal surgery is another strategy to optimize metabolic state and reduce prolonged nutrition deficits. In this paper, we review the importance of preoperative nutrition and strategies for effective preoperative nutrition optimization.

Nutrition support and therapy in patients with head and neck squamous cell carcinomas.

Head and neck squamous cell carcinomas (HNSCC) present a unique set of challenges in both the treatment of the disease and in support of the patient afflicted with the cancer. A major challenge is the nutritional support of these patients. Often, patients with HNSCC are malnourished at baseline due to an underlying dysphagia. Many others develop dysphagia as a result of their surgical resection and external beam radiation therapy. This dysphagia further exacerbates the chronic dehydration and malnutrition. This article will review strategies to provide nutritional support to HNSCC patients and also to review nutritional strategies that may decrease the morbidity and mortality associated with HNSCC treatment.

"CAN WE FEED?" A mnemonic to merge nutrition and intensive care assessment of the critically ill patient.

As care of the critically ill patient grows more complex, so does the breadth of knowledge required of the intensivist to deliver quality service. Nutrition is one area of many where the complexity of care has grown and the opportunity for improving patient outcomes has become evident. The use of mnemonics has proven successful in compartmentalizing information that must be considered in complex decision-making processes. The authors propose one such mnemonic, "CAN WE FEED?" to assist in the development and initiation of early enteral nutrition therapy in the intensive care unit (ICU). Critical illness severity (C), age (A), and nutrition risk screening (N) are considered when performing a baseline evaluation of the critically ill patient upon presentation to the ICU. Wait for resuscitation (W) is a key component in the care of most critically ill patients and is an important consideration prior to the initiation of feeding. Energy requirements (E) are determined using conventional weight-based equations, indirect calorimetry, or combinations of both techniques. The more practical aspects of support that follow include formula selection (F), enteral access (E), efficacy (E), and the determination of tolerance (D). With careful consideration of these components through the use of the mnemonic "CAN WE FEED?" the intensivist can successfully implement a nutrition plan, and the clinical nutritionist can appreciate where nutrition therapy appropriately intervenes in the initial resuscitation and management of the critically ill patient.