Enteral nutrition in critically ill patients

Critical illness, stress, and surgery place increased demands on the body's nutritional requirements. These conditions promote a catabolic state and negative nitrogen balance. Nutritional problems are common in critically ill patients. Nutritional supplementation affords the opportunity of slowing down or stopping the catabolic process, restoring nitrogen balance, and preventing malnutrition. Enteral nutrition preserve the integrity of the gastrointestinal mucosa and enhance immune function. Early enteral nutrition administration to critically ill patients can decrease the number of infectious complications, length of stay and mortality. However, early enteral nutrition in the critically ill is often limited by gastroparesis, which impairs gastric emptying, thereby promoting gastroesophageal reflux and aspiration pneumonia. However, Early enteral nutrition is the treatment of choice with an A level of recommendation for some authors. A total of two hundred critically ill adult patients were enrolled in the study. Daily 18-hrs enteral nutrition via a 14F gastric tube was initiated either immediately after stabilization in group I, or later than 48hrs after admition in group II. Residual gastric volume was measured every 6hrs, and enteral nutrition was discontinued if exceed 300ml or vomiting occurred. Nutritional outcome measures included the percentage of the goal rate achieved during the study period, volume ratio, and gastrointestinal complications rate. Clinical outcomes included the incidence of ventilator associated pneumonia, multiple organ failure score, the duration of mechanical ventilation, and the length of ICU stay. Overall, the evidence suggests that early enteral feeding is beneficial to critically ill patients. In our study early intervention was associated with shorter duration of mechanical ventilation and ICU stay. Patients in the early feeding group had less sever form of MOF, and decreased infectious complications and mortality. The early institution of nutritional support and the use of enteral nutrition optimize nutritional status of the patient and reduce complications associated with bowel rest resulting in improved clinical outcomes in critically ill patients

Sedation of elderly patients during endoscopic retrograde cholangiopancreatography

Patients who undergo flexible endoscopy suffer from periods of hemodynamic changes which may present risk for the development of complications. The aim of this work was to demonstrate the ability of Ketamine to reduce propofol sedative requirements, improve quality of recovery and decrease discharge time when used in the setting of ERCP in elderly patients. The study included 40 patients who were randomly divided into 2 equal groups to receive either propofol alone or propofoi-ketamine [0.25 mg.kg[-1]]. Patients were monitored for non-invasive blood pressure, three leads ECG and peripheral pulse oximetry. The total propofol dose used was compared in the two groups and time till discharge from recovery room were recorded The results showed that low dose of ketamine reduce propofol requirements used to sedate elderly patients during ERCP with significantly more stable hemodynamics, better oxygenation and earlier discharge

Neuraxial anesthesia in anticoagulated parturient-should we cancel ?

In this prospective study 16 parturients on chronic anticoagulant therapy for a history of life-threatening thromboembolic disease were scheduled for elective cesarean section under neuraxial block. They stopped taking warfarin 5 days prior to surgery and LMWH [1.5 mg.kg-1] was given twice daily sc 3 days before the operation. Heparin was stopped 12 hours before surgery regarding INR < 1.4 and restarted in the first post operative day/ Warfarin was restarted together with LMWH after stabilization of the patients medical conditions. LMWH was discontinued when INR > 2. The results were compared to a control group comprised of 16 randomly selected non warfarin treated parturients who underwent elective CS during the same period. Mean perioperative decrease in hemoglobin was 1.3 +/- 0.3 gm/dL and 1.4 +/- 0.1 gm/dL in heparin and control group respectively. The need for blood transfusion did not significantly differ between the two groups. Average hospitalization period in heparin group was 4.3 +/- 0.5 days compared to 2.2 +/- 0.3 days in the control group [P < 0.01]. No long term hemorrhage or thromboembolic complications were recorded 3 months postoperatively. Elective cesarean section under neuraxial block can be conducted safely in those high risk patients with regimen that allows a brief but controlled interruption to their full anticoagulation

Protection of cirrhotic liver during anesthesia

The combination of antioxidant compounds is beneficial to ameliorate hepatotoxicity in cirrhotic patient undergoing general anesthesia as indicated by reduction of the up-regulation of soluble adhesion molecule [sICAM-1] level and other liver functions. Twenty two surgical patients [child class A] divided into two groups. Antioxidant group: received one gm.h-1 of N-acetyl cysteine [Mucomyst] infusion after induction of anesthesia and continuously till the end of surgery. One gram of ascorbic acid [Vitamin C] and 400 IU of -tocopherol [Vitamin E] were administered iv over 10-15 min with closure of rectus sheath. The other group received equal volumes of normal saline during the same periods. Three blood samples were taken from every patient before induction of anesthesia, one hour and one day after surgery for measurement of sICAM-1 and other liver functions [total proteins, serum albumin, alanine aminotransferase [ALT], aspartate aminotransferase [AST], alkaline phosphatase [ALP], total and direct serum bilirubin]. sICAM-1 increased in both groups in the postoperative samples with more increase in saline group [P < 0.05]. Other liver functions showed significant increase in ALT, AST and ALP one hour postoperatively in saline group only. After one day they increased in both groups with more significant elevation in saline group. Serum total proteins, serum albumin, total and direct bilirubin showed no significant changes in both groups. These results proved that the combination of antioxidant compounds during general anesthesia in cirrhotic patient reduce the up-regulation of sICAM-1 which appear to be a good marker for hepatic impairments

Presentation of amniotic fluid embolism as acute hypoxia during elective cesarean section

A case of a pregnant woman undergoing an elective cesarean section [CS] who developed an intra-operative hypoxemia that was refractory to treatment with oxygen and ventilation is presented

Spinal ropivacaine for ambulatory surgery in critically ill patients

The aim of the present study was to compare spinal 0.25% hyperbaric ropivacaine [6 mg] to 0.25% hyperbaric bupivacaine [4 mg] to produce selective spinal anesthesia for ambulatory diabetic foot debridment in critically ill patients. Thirty patients aged >/= 70 years with ASA score of III-IV, type I diabetes mellitus, secondary hypertension and ischemic heart disease undergoing unilateral diabetic foot debridment [30 minutes duration] were included in the study. They were divided into two groups, 15 patients each. The peak sensory level in the operative side was nearly equal in both groups [T[10]]. Time to peak sensory block was significantly longer, however the duration of sensory block was significantly shorter in ropivacaine group compared to bupivacaine group [18 +/- 2 min and 90 +/- 10 min versus 15 +/- 2 min and 115 +/- 10 min respectively]. Time to maximum motor block was equal in both groups [17 min]. However duration of motor block, time to walk and time to void were significantly shorter in ropivacaine group [100 +/- 8 min, 130 +/- 10 min and 160 +/- 15 min] respectively, in comparison to bupivacaine group [119 +/- 10 min. 142 +/- 12 min and 180 +/- 10 min]. These data suggest that the 6 mg dose of 0.25% hyperbaric ropivacaine is as effective as the 4mg dose of 0.25% hyperbaric bupivacaine in ambulatory diabetic foot debridment, however superior to produce more selective spinal anaesthesia with shorter duration of sensory and motor block

Perispinal morphine for relief after perianal surgery

Perispinal anesthesia allows injection of epidural [ED] or intrathecal [i.t] morphine to provide long-lasting postoperative analgesia. To compare these two routes, a prospective, randomized study of 40 patients undergoing perianal surgery was performed. Combined spinal-epidural anesthesia with 6 mg of i.t. hyperbaric bupivacaine plus sufentanil 5 micro g and additional ED lidocaine was used. Additionally, each patient received either 2mg [2 ml] of ED morphine plus 1 ml of i.t. normal saline [ED group, n =20] or 0.075 mg [1 ml] of i.t. morphine plus 2 ml of ED normal saline [i.t. group n = 20]. Parentral propacetamol was given for additional postoperative analgesia. No major respiratory depression occurred. Time for first demand of propacetamol was similar in the ED and i.t. groups [250 min]. During the first 24 postoperative hours, VAS pain scores were greater in the i.t. group [p =0.03]. The incidence of side effects such as sedation, pruritis, nausea and vomiting was equal in both groups. The ED protocol was more effective than the i.t. protocol, whilest side-effects were similar