Banana flakes control diarrhea in enterally fed patients.

Diarrhea occurs frequently in the critically ill tube-fed population and may result from a multitude of causes. Despite the availability of antidiarrheal medications, diarrhea associated with enteral feedings remains a problem for clinicians and for the patients affected by it. We tested the hypothesis that administration of banana flakes would control diarrhea in critically ill patients receiving enteral feedings. Thirty-one patients with diarrhea and receiving enteral feedings were randomized to receive either banana flakes or medical treatment for diarrhea. Medical treatments included the use of pharmacological agents according to the discretion of the patient's physician or reducing feeding rates. Both banana flakes and medical treatments reduced the severity of diarrhea in critically ill tube-fed patients. Over the course of treatment, mean diarrhea scores were 21.64 +/- 7.81 for the banana flake group and 25.41 +/- 9.76 for the medical group. These differences were not statistically significant. Both groups achieved similar levels of nutrition support. The banana flake group had less diarrhea clinically, with 57% of the subjects diarrhea free on their last study day as opposed to 24% of the medically treated subjects. This occurred despite a threefold increase in the number of patients testing positive for Clostridium difficile toxin in the banana flake group. We conclude that banana flakes can be used as a safe, cost-effective treatment for diarrhea in critically ill tube-fed patients. Banana flakes can be given concurrently with a workup for C. difficile colitis, thereby expediting treatment of diarrhea.

Surgical treatment of persistent exit-site infections.

Persistent exit-site infections and tunnel infections (ESI/TI) are a cause for removal of Swan neck catheters (SNC). Previous studies report variable success in the treatment of these infections by surgical exposure and removal of the subcutaneous external cuff. We report our experience with this technique. All 5 patients with persistent ESI/TI were successfully treated with antibiotics and surgical intervention. All cultures grew Staphylococcus aureus. Average time to complete healing after surgical exposure was 39.4 days. Mean follow-up after complete healing was 164.8 days. There were no subsequent episodes of ESI/TI in these patients. None of the catheters subsequently malfunctioned or developed leaks. Persistent ESI/TI in Swan neck catheters can be successfully treated with surgical exposure and removal of the subcutaneous external cuff.

Acid dialysate correction of metabolic alkalosis in renal failure.

Severe metabolic acidosis may occur during hemodialysis when the incorrect acid dialysis concentrate from a two-part bicarbonate dialysis system is used in an acetate dialysis machine. We deliberately applied this technique to correct severe metabolic alkalosis in a patient with chronic renal failure. Rapid correction of the metabolic alkalosis was achieved and the procedure was well tolerated.

Effects of feto-placental markers with plasma exchange in pregnancy.

To evaluate changes in feto-placental markers with plasma exchange in pregnancy, two patients at varying stages of pregnancy referred to a tertiary care hospital and requiring plasma exchange for intercurrent problems were evaluated. Alpha-fetoprotein, human chorionic gonadotropin, and free estriol were sequentially measured in the patients' plasma and in the fluid removed, thus permitting calculations of permeability rates and clearances. Despite markedly different molecular weights, all three feto-placental markers had similar permeabilities and clearances. While in both patients maternal levels of alpha-fetoprotein and human chorionic gonadotropin decreased rapidly with plasma separation and rebounded rapidly to baseline, free estriol responded differently and did not appear to decrease with therapy. Maternal levels of feto-placental markers only transiently changed with plasma exchange during pregnancy and rapidly returned to baseline with no apparent consequences to the pregnancy.

Acute plasma separation with hemodialysis equipment.

Although plasma separation has been reported to have a relatively small complication rate in large series of healthy outpatients, little attention has been directed to the evaluation of the safety and effectiveness of the therapy in acutely ill, hospitalized patients. The experience of using standard hemodialysis equipment and membrane plasma separators with 281 plasma separation treatments in 49 patients over the last 7 yr is reported and analyzed. The data reveal a 1.4% incidence of hypotension and a 0.4% incidence of hematuria in the 281 treatments--rates similar to those reported in outpatients. In addition, analysis of the diseases and patients treated over the 7 yr reported demonstrates a marked shift from immunological and hematological disorders towards neurological disorders. The data suggest that plasma separation may be easily and safely performed by any institution capable of performing acute hemodialysis.

Adequacy of dialysis in CAPD and cycler PD; the PET is enough.

Assessment of adequacy of dialysis has become a necessary part of all peritoneal dialysis programs; this task is particularly burdensome in home cycler patients. To test the hypothesis that the Peritoneal Equilibration Test (PET) reliably predicts clearance, as measured by classical clearance methodology, both CAPD and cycler patients underwent PET tests and clearance studies. In cycler patients, Dialysis to Plasma Ratios (D/P) for urea nitrogen (UN) and D/P for creatinine as determined by clearance methods correlated extremely well with those obtained by PET test. D/P creatinine also correlated well (clearance versus PET) in CAPD patients; D/P UN approached unity in all CAPD patients with dwell times of 4 hours or longer. In all cases, the PET prescription was highly accurate in predicting 24-hour clearance results. These results are useful in those patients in whom 24-hour home collections are inconvenient or impossible, especially in cycler patients.

Base secretion in rat distal colon: ionic requirements.

To evaluate the ionic requirements of colonic base secretion, segments of rat distal colon were studied under short-circuited conditions. Net base flux was composed of an active secretory component and a diffusive component. Studied in the absence of a transepithelial HCO3- concentration gradient, active base secretion was dependent on the HCO3- concentration of the bathing solution but was not influenced by the CO2 tension or pH. Base secretion appeared to saturate with a Km of 33 +/- 9 mM and was inhibited by ouabain. The diffusive component was characterized by an apparent permeability coefficient to HCO3- of 8.9 +/- 0.9 x 10(-6) cm/s. In addition to requiring HCO3- on the serosal surface, net base secretion was inhibited by reducing the Na+ concentration in the serosal medium and the Cl- concentration in the mucosal medium. These data suggest that colonic base secretion involves HCO3- entry across the basolateral surface, energized by the Na+ gradient, and HCO3- exit across the apical surface in exchange for Cl-.

Progression of membranous nephropathy to acute crescentic rapidly progressive glomerulonephritis and response to pulse methylprednisolone.

There have been only sporadic reports of membranous nephropathy (MN) evolving into acute crescentic rapidly progressive glomerulonephritis (AC-RPGN). A patient with MN developed acute oliguric renal failure with a serum creatinine (SCr) of 8.4 mg/dl after 5 years of normal renal function. Biopsy now revealed epithelial crescent formation superimposed on MN. Pulse methylprednisolone resulted in significant improvement in renal function, with a SCr of 2.2 mg/dl at 6 months. No other favorable outcomes occurred in the 4 previous case reports of MN evolving into RPGN. AC-RPGN should be considered a treatable etiology of acute renal failure in the setting of MN.