Micronutrient deficiencies in critically ill patients receiving continuous renal replacement therapy.

BACKGROUND & AIMS: Continuous renal replacement therapy (CRRT) is essential to the management of acute kidney injury (AKI) in critical illness. Unfortunately, large quantities of micronutrients are shown to be lost in CRRT effluent. Current literature describes serum micronutrient values in CRRT patients to be below-reference range, yet seldom compares such values to other critically ill populations unexposed to CRRT. The aim of this study was to describe and compare the prevalence of micronutrient and carnitine deficiencies in critically ill patients at high malnutrition risk exposed to CRRT to a group of patient unexposed to CRRT. METHODS: A retrospective chart review was conducted at Duke University Hospital using the electronic medical record. The study group consisted of patients at high malnutrition risk requiring intensive care unit (ICU) admission from 01/01/2017-12/31/2018 with one or more of the following serum micronutrient levels checked: carnitine, copper, zinc, selenium, and vitamins B1, B6, B9, and C. Micronutrient deficiencies were defined as below the reference range and carnitine deficiencies were interpreted as an acyl to free carnitine ratio (ACFR) of >0.4. RESULTS: 106 ICU patients met inclusion criteria and 46% were exposed to CRRT. At least one micronutrient deficiency was reported in 90% of CRRT patients compared to 61% patients unexposed to CRRT (p = 0.002). A greater percentage of copper (p < 0.001) and carnitine (p < 0.001) deficiencies were found among patients exposed to CRRT, while more zinc deficiencies were noted among non-CRRT patients (p = 0.001). CONCLUSIONS: The vast majority of CRRT patients presented with micronutrient deficiencies. Clinicians should have a heightened awareness of the risk for serum copper, carnitine, and vitamin B6 deficiencies among CRRT patients. Further prospective and randomized-controlled trials are needed to better define this new category of malnutrition and test supplementation strategies to address and prevent these clinically-relevant deficiencies.

Association between early postoperative nutritional supplement utilisation and length of stay in malnourished hip fracture patients.

BACKGROUND: Malnutrition in older hip fracture patients is associated with increased complication rates and mortality. As postoperative nutrition delivery is essential to surgical recovery, postoperative nutritional supplements including oral nutritional supplements or tube feeding formulas can improve postoperative outcomes in malnourished hip/femur fracture patients. The association between early postoperative nutritional supplements utilisation and hospital length of stay was assessed in malnourished hip/femur fracture patients. METHODS: This is a retrospective cohort study of malnourished hip/femur fracture patients undergoing surgery from 2008 to 2018. Patients were identified through International Classification of Diseases, Ninth Revision (ICD-9) and Tenth Revision (ICD-10) codes and nutritional supplement utilisation via hospital charge codes. The primary outcome was hospital length of stay. Secondary outcomes included infectious complications, hospital mortality, ICU admission, and costs. Propensity matching (1:1) and univariable analysis were performed. RESULTS: Overall, 160 151 hip/femur fracture surgeries were identified with a coded-malnutrition prevalence of 8.7%. Early postoperative nutritional supplementation (by hospital day 1) occurred in 1.9% of all patients and only 4.9% of malnourished patients. Propensity score matching demonstrated early nutritional supplements were associated with significantly shorter length of stay (5.8 [6.6] days vs 7.6 [5.8] days; P<0.001) without increasing hospital costs. No association was observed between early nutritional supplementation and secondary outcomes. CONCLUSION: Malnutrition is underdiagnosed in hip/femur fracture patients, and nutritional supplementation is underutilised. Early nutritional supplementation was associated with a significantly shorter hospital stay without an increase in costs. Nutritional supplementation in malnourished hip/femur fracture patients could serve as a key target for perioperative quality improvement.

Postoperative Utilization of Oral Nutrition Supplements in Surgical Patients in US Hospitals.

BACKGROUND: Postoperative nutrition delivery is essential to surgical recovery; unfortunately, postoperative dietary intake is often poor. Recent surgical guidelines recommend use of oral nutritional supplements (ONS) to improve nutrition delivery. Our aim was to examine prevalence of coded ONS use over time and coded malnutrition rates in postoperative patients. METHODS: The Premier Healthcare Database (PHD) was queried for postoperative patients found to have charges for ONS between 2008-2014. ONS use identified via charge codes. Descriptive statistics utilized to examine prevalence of malnutrition and ONS utilization. Multilevel, multivariable logistic regression models were fit to examine factors associated with ONS use. RESULTS: A total of 2,823,532 surgical encounters were identified in PHD in 172 hospitals utilizing ONS charge codes. ONS-receiving patients were 72% Caucasian, 65% Medicare patients with mean age of 66 ± 16.5 years. Compared with patients not receiving ONS, ONS patients had higher van Walraven severity scores (7.3 ± 7.8 vs 2.3 ± 5.6, P < .001) with greater comorbidities. Overall coded malnutrition prevalence was 4.3%. Coded malnutrition diagnosis increased from 4.4% to 5.2% during study period. Only 15% of malnourished patients received ONS. Individual hospital practice explained much of variation in early postoperative ONS use. CONCLUSION: In this large surgical population, inpatient ONS use is most common in older, Caucasian, Medicare patients with high comorbidity burden. Despite increased malnutrition during study period, observed ONS prescription rate did not increase. Our data indicate current ONS utilization in surgical patients, even coded with malnutrition, is limited and is a critical perioperative quality improvement opportunity.

Impact of early postoperative oral nutritional supplement utilization on clinical outcomes in colorectal surgery.

BACKGROUND: Small randomized trials of early postoperative oral nutritional supplementation (ONS) suggest various health benefits following colorectal surgery (CRS). However, real-world evidence of the impact of early ONS on clinical outcomes in CRS is lacking. METHODS: Using a nationwide administrative-financial database (Premier Healthcare Database), we examined the association between early ONS use and postoperative clinical outcomes in patients undergoing elective open or laparoscopic CRS between 2008 and 2014. Early ONS was defined as the presence of charges for ONS before postoperative day (POD) 3. The primary outcome was composite infectious complications. Key secondary efficacy (intensive care unit (ICU) admission and gastrointestinal complications) and falsification (blood transfusion and myocardial infarction) outcomes were also examined. Propensity score matching was used to assemble patient groups that were comparable at baseline, and differences in outcomes were examined. RESULTS: Overall, patients receiving early ONS were older with greater comorbidities and more likely to be Medicare beneficiaries with malnutrition. In a well-matched sample of early ONS recipients (n = 267) versus non-recipients (n = 534), infectious complications were significantly lower in early ONS recipients (6.7% vs. 11.8%, P < 0.03). Early ONS use was also associated with significantly reduced rates of pneumonia (P < 0.04), ICU admissions (P < 0.04), and gastrointestinal complications (P < 0.05). There were no significant differences in falsification outcomes. CONCLUSIONS: Although early postoperative ONS after CRS was more likely to be utilized in elderly patients with greater comorbidities, the use of early ONS was associated with reduced infectious complications, pneumonia, ICU admission, and gastrointestinal complications. This propensity score-matched study using real-world data suggests that clinical outcomes are improved with early ONS use, a simple and inexpensive intervention in CRS patients.

Geospatial Variations and Neighborhood Deprivation in Drug-Related Admissions and Overdoses.

Drug overdoses are a national and global epidemic. However, while overdoses are inextricably linked to social, demographic, and geographical determinants, geospatial patterns of drug-related admissions and overdoses at the neighborhood level remain poorly studied. The objective of this paper is to investigate spatial distributions of patients admitted for drug-related admissions and overdoses from a large, urban, tertiary care center using electronic health record data. Additionally, these spatial distributions were adjusted for a validated socioeconomic index called the Area Deprivation Index (ADI). We showed spatial heterogeneity in patients admitted for opioid, amphetamine, and psychostimulant-related diagnoses and overdoses. While ADI was associated with drug-related admissions, it did not correct for spatial variations and could not account alone for this spatial heterogeneity.

Tutorial: Development and Implementation of a Multidisciplinary Preoperative Nutrition Optimization Clinic.

Although much is known about surgical risk, little evidence exists regarding how best to proactively address preoperative risk factors to improve surgical outcomes. Preoperative malnutrition is a widely prevalent and modifiable risk factor in patients undergoing surgery. Malnutrition prior to surgery portends significantly higher postoperative mortality, morbidity, length of stay, readmission rates, and hospital costs. Unfortunately, perioperative malnutrition is poorly screened for and remains largely unrecognized and undertreated-a true "silent epidemic" in surgical care. To better address this silent epidemic of surgical nutrition risk, here we describe the rationalization, development, and implementation of a multidisciplinary, registered dietitian-driven, preoperative nutrition optimization clinic program designed to improve perioperative outcomes and reduce cost. Implementation of this novel Perioperative Enhancement Team (POET) Nutrition Clinic required a collaboration among many disciplines, as well as an identified need for multidimensional scheduling template development, data tracking systems, dashboard development, and integration of electronic health records. A structured malnutrition risk score (Perioperative Nutrition Screen score) was developed and is being validated. A structured malnutrition pathway was developed and is under study. Finally, the POET Nutrition Clinic has established a novel role for a perioperative registered dietitian as the integral point person to deliver perioperative nutrition care. We hope this structured model of perioperative nutrition assessment and optimization will allow for wide implementation and generalizability in other centers worldwide to improve recognition and treatment of perioperative nutrition risk.

Perioperative Nutrition Care of Orthopedic Surgery Patient.

Despite evidence that malnutrition is associated with significant complications in orthopedic surgery1, unrecognized malnutrition continues to be a "silent epidemic", effecting up to 50% of hospitalized patients. Specifically, pre-surgical malnutrition is associated with increased risk for surgical site infections, increased length of hospital stay, and increased health care costs in patients following total joint arthroplasty. Serologic markers (i.e. serum albumin and total lymphocyte count), anthropometric measurements, (i.e. calf muscle circumference and triceps skin fold) and assessment and screening tools (i.e. The Rainey-MacDonald Nutritional Index, the Mini Nutrition Assessment Short Form, the Malnutrition Universal Screening Tool and the Nutrition Risk Screening 2002) have all been used to aid in the diagnosis of malnutrition in orthopedic patients, yet there is no universal gold standard for screening or assessing nutritional risk and no accepted guideline for perioperative nutritional optimization in this patient population. Recently, the Perioperative Nutrition Screen (PONS) was introduced2 as an easy and efficient way to preoperatively identify and risk stratify patients for malnutrition in order to guide perioperative nutrition optimization. Given malnutrition is associated with increased risk of surgical site infections and increased length of hospital stay, adequate assessment of perioperative risk for malnutrition and preoperative nutrition optimization, including structured weight loss in the obese population, consumption of high protein oral nutritional supplements, immunonutrition oral supplements and adequate glucose control, may improve perioperative outcomes. The presence of a Registered Dietician (RD) should be a standard of care in all pre-operative clinics to improve nutrition care and surgical outcomes.

Focused cardiac ultrasound in preoperative assessment: the perioperative provider's new stethoscope?

Focused cardiac ultrasound (FoCUS)-a simplified, qualitative version of echocardiography-is a well-established tool in the armamentarium of critical care and emergency medicine. This review explores the extent to which FoCUS could also be used to enhance the preoperative physical examination to better utilise resources and identify those who would benefit most from detailed echocardiography prior to surgery. Among the range of pathologies that FoCUS can screen for, the conditions it provides the most utility in the preoperative setting are left ventricular systolic dysfunction (LVSD) and, in certain circumstances, significant aortic stenosis (AS). Thus, FoCUS could help answer two common preoperative diagnostic questions. First, in a patient with high cardiovascular risk who subjectively reports a good functional status, is there evidence of LVSD? Second, does an asymptomatic patient with a systolic murmur have significant aortic stenosis? Importantly, many cardiac pathologies of relevance to perioperative care fall outside the scope of FoCUS, including regional wall motion abnormalities, diastolic dysfunction, left ventricular outflow obstruction, and pulmonary hypertension. Current evidence suggests that after structured training in FoCUS and performance of 20-30 supervised examinations, clinicians can achieve competence in basic cardiac ultrasound image acquisition. However, it is not known precisely how many training exams are necessary to achieve competence in FoCUS image interpretation. Given the short history of FoCUS use in preoperative evaluation, further research is needed to determine what additional questions FoCUS is suited to answer in the pre-operative setting.

The malnourished surgery patient: a silent epidemic in perioperative outcomes?

PURPOSE OF REVIEW: As many as two of every three major surgery patients are malnourished preoperatively - a diagnosis rarely made and treated even less frequently. Unfortunately, perioperative malnutrition is perhaps the least often identified surgical risk factor and is among the most treatable to improve outcomes. RECENT FINDINGS: Two important perioperative nutrition guidelines were published recently. Both emphasize nutrition assessment as an essential component of preoperative screening. The recently published perioperative nutrition screen (PONS) readily identifies patients at malnutrition risk, allowing for preoperative nutritional optimization. The use of computerized tomography scan and ultrasound lean body mass (LBM) evaluation to identify sarcopenia associated with surgical risk and guide nutrition intervention is garnering further support. Preoperative nutrition optimization in malnourished patients, use of immunonutrition in all major surgery, avoidance of preoperative fasting, inclusion of postoperative high-protein nutritional supplements, and early postoperative oral intake have all recently been shown to improve outcomes and should be utilized. SUMMARY: The recent publication of new surgical nutrition guidelines, the PONS score, and use of LBM assessments will allow better identification and earlier intervention on perioperative malnutrition. It is essential that in the future no patient undergoes elective surgery without nutrition screening and nutrition intervention when malnutrition risk is identified.

The rising tide of opioid use and abuse: the role of the anesthesiologist.

Opioid use has risen dramatically in the past three decades. In the USA, opioid overdose has become a leading cause of unintentional death, surpassing motor vehicle accidents. A patient's first exposure to opioids may be during the perioperative period, a time where anesthesiologists have a significant role in pain management. Almost all patients in the USA receive opioids during a surgical encounter. Opioids have many undesirable side effects, including potential for misuse, or opioid use disorder. Anesthesiologists and surgeons employ several methods to decrease unnecessary opioid use, opioid-related adverse events, and side effects in the perioperative period. Multimodal analgesia, enhanced recovery pathways, and regional anesthesia are key tools as we work towards optimal opioid stewardship and the ideal of effective analgesia without undesirable sequelae.