A simplified approach to the management of gastric residual volumes in critically ill mechanically ventilated patients: a pilot prospective cohort study.

BACKGROUND: Enteral nutrition in the critically ill patient is often complicated by gastrointestinal intolerance, manifested by a large gastric residual volume. The frequency of GRV assessment and the intolerant level above which feeding is stopped is controversial. OBJECTIVES: To evaluate a novel approach to EN by allowing high GRV and once-daily assessment that was correlated with the paracetamol absorption test. METHODS: We conducted a pilot prospective study in an 18 bed general intensive care unit. The study group comprised 52 consecutive critically ill mechanically ventilated patients. Enteral nutrition was started at full delivery rate. Once-daily assessment of GRV with three consecutively repeated threshold volumes of 500 ml was performed before stopping EN. The paracetamol absorption test was performed and correlated to GRV. Patients were divided into two groups: low GRV (< 500 ml) and high GRV (at least one measurement of GRV > 500 ml). Clinical outcome included maximal calories delivered, incidence of pneumonia, ICU length of stay, and ICU and hospital mortality. RESULTS: There were 4 patients (9.5%) with ventilator-associated pneumonia in the low GRV group and 3 (30%) in the high GRV group (P = 0.12). GRV was inversely correlated to paracetamol absorption; however, neither GRV nor paracetamol absorption was associated with the development of pneumonia. Both groups had similar ICU length of stay (11.0 +/- 8.2 vs. 13.8 +/- 14.4 days, P = 0.41), and similar ICU (21% vs. 40%, P = 0.24) and hospital mortality (35% vs. 40%, P = 1.0). CONCLUSIONS: In critically ill mechanically ventilated patients, allowing larger gastric residual volumes, measured once daily, enables enteral feeding with fewer interruptions which results in high calorie intake without significant complications or side effects.

Salmonellosis: an epidemiologic study.

BACKGROUND: Salmonella species commonly produce acute gastroenteritis. The clinical course may be affected by factors such as age, immunosuppression, and underlying disorders. OBJECTIVES: To investigate clinical and laboratory differences in the infected population and the risk of complications according to the different age groups. METHODS: The records of 295 patients with positive cultures for Salmonella were divided into six age groups and reviewed retrospectively for the years 1994-1997. Demographic, clinical and laboratory data, extraintestinal manifestations, underlying disorders, organism source, and susceptibilty to antibiotics were analyzed. RESULTS: We found that 88.5% were only stool positive, 9.2% had positive blood cultures, and 2.4% were positive in both blood and stool; 3.6% were found to have underlying disorders. Anemia, disturbed liver function tests and hypoalbuminemia were the most common pathologic laboratory findings. Salmonella serogroups B and D were isolated most frequently. The rate of positive blood cultures increased significantly during the years, as did resistance to ampicillin and trimethoprimsulfamethoxazole. Salmonella infection has two peaks of incidence: at ages 1-5 and 15-65 years. Bacteremia was prominent in the extreme ages. CONCLUSIONS: Salmonella infection has a different clinical presentation in different age groups. The significant increase in the rate of bacteremia in the extreme age groups necessitates a different attitude and management for these heterogeneous patient populations.