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A 28-year-old female presented to the Emergency Department (ED) with a chief complaint of strings protruding from her vagina. The patient also complained of recurrent symptoms of cystitis and occasional hematuria over the past five months without resolution after treatment. The patient underwent ED evaluation and was noted to have strings coated in calculus protruding from her urethral meatus. On AP abdominal film a T-shaped intrauterine device (IUD) with calculus was noted in the pelvis. By computed tomography (CT) scan the object was shown to be extruding from the vagina into the bladder. Of note the patient had a history of IUD use with supposed removal five years prior to presentation. The diagnosis of IUD perforation of the bladder with calculus formation was confirmed by cystoscopy, and the IUD and calculi were successfully removed without complication.

Background: Malnutrition and underfeeding are major challenges in caring for critically ill patients. Our goal was to characterize interruptions in enteral nutrition (EN) delivery and their impact on caloric debt in the surgical intensive care unit (ICU)., Materials and Methods: We performed a prospective, observational study of adults admitted to surgical ICUs at a Boston teaching hospital (March-December 2012). We categorized EN interruptions as "unavoidable" vs "avoidable" and compared caloric deficit between patients with ≥1 EN interruption (group 1) vs those without interruptions (group 2). Multivariable logistic regression was used to investigate the association of EN interruption with the risk of underfeeding. Poisson regression was used to investigate the association of EN interruption with length of stay (LOS) and mortality., Results: Ninety-four patients comprised the analytic cohort. Twenty-six percent of interruptions were deemed "avoidable." Group 1 (n = 64) had a significantly higher mean daily and cumulative caloric deficit vs group 2 (n = 30). Patients in group 1 were at a 3-fold increased risk of being underfed (adjusted odds ratio, 2.89; 95% confidence interval [CI], 1.03-8.11), had a 30% higher risk of prolonged ICU LOS (adjusted incident risk ratio [IRR], 1.27; 95% CI, 1.14-1.42), and had a 50% higher risk of prolonged hospital LOS (adjusted IRR, 1.53; 95% CI, 1.41-1.67) vs group 2., Conclusions: In our cohort of critically ill surgical patients, EN interruption was frequent, largely "unavoidable," and associated with undesirable outcomes. Future efforts to optimize nutrition in the surgical ICU may benefit from considering strategies that maximize nutrient delivery before and after clinically appropriate EN interruptions., (© 2014 American Society for Parenteral and Enteral Nutrition.)