Enteral nutrition preference in critical care: fibre-enriched or fibre-free?

BACKGROUND AND OBJECTIVES: This study's main aim was to observe the effects of a fibre-enriched nutrition solution on requisite feeding volume, which is directly proportional to energy intake in mechanically ventilated patients with enteral nutrition. METHODS AND STUDY DESIGN: Some 120 patients who required mechanical ventilation and enteral nutrition with a nasogastric tube were studied. Upon ICU admission, the patient's age, gender, weight, height, comorbidities, diagnosis and APACHE II score were recorded. We assigned two diets to the patients randomly. The control group received the fibre-free nutrition solution. The study group, received the fibreenriched nutrition solution. Prescribed feeding volume and administered feeding volume, gastric residual volume (GRV), volume ratio (VR), diarrhoea score and gastrointestinal complications (GIC) were recorded, along with daily biochemistry. RESULTS: The two groups did not differ with respect to age, sex, weight, BMI, APACHE II score, target caloric intake or GRV (p>0.05). On days four and five, the study group had higher VR values (p<0.05). Seventy-one (59%) patients had at least one gastrointestinal complication; 44 (73%) of them were controls and 27 (45%) of them study patients. The most commonly observed GIC was diarrhoea. Thirty-eight patients had diarrhoea in control group, and twenty-two patients had diarrhoea in study group, and this difference was statistically significant (p<0.001). There were no significant differences between the groups about vomiting and regurgitation. CONCLUSIONS: We suggest that ICU staff initiate enteral nutrition with fibre-enriched formulas rather than fibre-free formulas to avoid frequent feeding interruptions that cause protein energy malnutrition in ICU patients.

Diphenylhydantoin Induced DRESS Syndrome: A Case Report.

Drug Rash with Eosinophilia and Systemic Symptoms" (DRESS) syndrome is a severe adverse drug reaction. The drugs most often implicated are anti-convulsants, bupropion, sulfonamides, sulfasalazine, allopurinol, minocycline, abacavir and neviparine. There are also immune and infectious causes that can lead to DRESS syndrome. A 70-year-old female patient had undergone endovascular coil embolization for intracranial aneurysm and experienced a generalised seizure postoperatively. She had been given diphenylhidantoin (DPH). Six days after DPH therapy, the patient had complained of widespread skin rash. Although DPH was replaced with levetiracetam afterwards, the skin rash deteriorated, causing facial oedema and swelling of the tongue. She had severe facial oedema with swelling of the tongue, causing disturbance of breathing. On the second day in the critical care unit, the patient's breathing deteriorated, leading successively to intubation and mechanical ventilation. The patient's rash was still persistent and the results of a punch biopsy taken from the lesions revealed superficial perivascular dermatitis involving spongiotic eosinophils compatible with spongiotic drug eruption. As a result, it is important to realise that medications we use can be the cause of a range of reactions ranging from simple rash to life threatening syndromes.

Regulation of sarcoplasmic reticulum Ca2+ reuptake in porcine airway smooth muscle.

Regulation of intracellular Ca(2+) concentration ([Ca(2+)](i)) in airway smooth muscle (ASM) during agonist stimulation involves sarcoplasmic reticulum (SR) Ca(2+) release and reuptake. The sarco(endo)plasmic reticulum Ca(2+)-ATPase (SERCA) is key to replenishment of SR Ca(2+) stores. We examined regulation of SERCA in porcine ASM: our hypothesis was that the regulatory protein phospholamban (PLN) and the calmodulin (CaM)-CaM kinase (CaMKII) pathway (both of which are known to regulate SERCA in cardiac muscle) play a role. In porcine ASM microsomes, we examined the expression and extent of PLN phosphorylation after pharmacological inhibition of CaM (with W-7) vs. CaMKII (with KN-62/KN-93) and found that PLN is phosphorylated by CaMKII. In parallel experiments using enzymatically dissociated single ASM cells loaded with the Ca(2+) indicator fluo 3 and imaged using fluorescence microscopy, we measured the effects of PLN small interfering RNA, W-7, and KN-62 on [Ca(2+)](i) responses to ACh and direct SR stimulation. PLN small interfering RNA slowed the rate of fall of [Ca(2+)](i) transients to 1 microM ACh, as did W-7 and KN-62. The two inhibitors additionally slowed reuptake in the absence of PLN. In other cells, preexposure to W-7 or KN-62 did not prevent initiation of ACh-induced [Ca(2+)](i) oscillations (which were previously shown to result from repetitive SR Ca(2+) release/reuptake). However, when ACh-induced [Ca(2+)](i) oscillations reached steady state, subsequent exposure to W7 or KN-62 decreased oscillation frequency and amplitude and slowed the fall time of [Ca(2+)](i) transients, suggesting SERCA inhibition. Exposure to W-7 completely abolished ongoing ACh-induced [Ca(2+)](i) oscillations in some cells. Preexposure to W-7 or KN-62 did not affect caffeine-induced SR Ca(2+) release, indicating that ryanodine receptor channels were not directly inhibited. These data indicate that, in porcine ASM, the CaM-CaMKII pathway regulates SR Ca(2+) reuptake, potentially through altered PLN phosphorylation.