Early enteral nutrition in gastrointestinal surgery: a pilot study

Hot tar burns compose a unique class of thermal injury, because removal of this highly sticky compound may be very difficult without inflicting additional tissue damage. Early removal of tar facilitates assessment of the burn and improves patient comfort. Although the use of many substances for the painless removal of tar has been described, we used sunflower oil effectively in the treatment of four tar burn patients. This first report describes the practical and successful use of sunflower oil which was easily obtained from the hospital kitchen.     

Early postoperative feeding after elective colorectal surgery is not a benefit unique to laparoscopy-assisted procedures

Fungal infection of the face is frequently misdiagnosed, since the typical ringworm, erythematous, slightly scaling, indistinct borders are only uncommonly seen on the face. Herpes zoster is a common infection caused by the varicella-zoster virus that transmits varicella (chickenpox). Granulomatous reactions such as granuloma annulare, pseudolymphoma, sarcoidal reaction, and eruptive keratoacanthoma have been described in herpes zoster scars. We describe here the first reported case of dermatophytosis occurring in healing herpes zoster lesions. This condition has not been previously reported.     

Endoscopic nasoenteral feeding tube placement following cardiothoracic surgery

Intraluminal incision is often used for the treatment of strictures of both the upper and the lower urinary tracts. The depth of the stricture and the location of surrounding structures such as blood vessels are important factors in guiding the incision. Endoluminal ultrasonography has been shown to be effective in defining periureteral anatomy accurately. A new device is described that combines an endoluminal ultrasound transducer and cutting device (electrocautery or laser fiber) in 9F catheter. This catheter was evaluated in two live anesthetized pigs (four kidneys) and four ex-vivo kidneys. Incisions were made at the ureteropelvic junction and middle and distal ureter. The ability to image the periureteral structures and to direct the location and the adequacy of the incision were assessed. Endoluminal ultrasound imaging was excellent, and the electrocautery wire was well seen. Well-defined, limited, full-thickness incisions were made using this device and could be directed accurately toward or away from periureteral vessels. This study demonstrates the potential for endoluminal ultrasound guidance of intraluminal incisions.     

Outcome of long-term enteral feeding

In the past two decades, many technical advances have made tube enteral feeding much more comfortable and acceptable to patients and their families. This has greatly expanded the use of this therapy, both in clinical conditions where it was traditionally prescribed and in many other diagnoses. This expanded use raises important questions about how much enteral nutrition is being used, the medical outcome in different clinical conditions, and the quality of life experienced by long-term therapy users. This article addresses these outcome issues for patients in the nonhospital setting.     

Complications following major abdominal surgery in cirrhotic patients

The morbidity and mortality associated with major abdominal surgical interventions in 34 histologically proven cirrhotic patients are analyzed by the authors. The surgical interventions were carried out as urgent, absolute and elective indications. Thirty-seven general and surgical complications were observed following major abdominal surgery in 34 cirrhotics. Seven out of 34 patients died, giving a mortality rate of 21%. Suture-line insufficiency, peritonitis, sepsis and other inflammatory processes turned out to be the most common complications. Statistical analysis showed that the Child criteria, prothrombin level and white blood cell count were useful prognostic factors.     

Effect of early postoperative enteral nutrition on postoperative infections

We undertook this study to test the hypothesis that early enteral nutrition might reduce the incidence of serious complications after major abdominal surgery. In a randomized double blind prospective trial 30 patients received Nutridrink and 30 patients received placebo through a nasoduodenal feeding tube. On the day of operation the patients were given median 600 ml nutrition/placebo, 60 ml/h. On the first postoperative day the patients received median 1000 ml nutrition/placebo, second day median 1200 ml nutrition, 1400 ml placebo, third postoperative day median 1000 ml nutrition, 1150 ml placebo and 4th postoperative day median 1000 ml nutrition, 800 ml placebo. All patients were followed for 30 days by the same investigator. The two groups were not different with regard to nutritional status and type of operation. The rate of postoperative infectious complications was significantly lower in the nutrition group, 2/30 compared to 14/30 in the placebo group (p = 0.0009). We conclude that early enteral nutrition given to patients after major abdominal surgery is followed by a major reduction in infectious complications.     

Ketorolac and diclofenac for postoperative pain relief following oral surgery

Revascularization of severely ischemic limbs was performed on 212 limbs of 156 patients by creating an arteriovenous fistula between the arterial trunk proximal to the obliteration and a deep venous trunk of the ischemic limb, constricting the venous trunk proximal to the anastomosis by two thirds of its original diameter, ligating rami communicans and small tributaries of the deep vein distal to the fistula. The results of experimental and clinical studies showed that the ischemic limb was quickly revascularized and the cardiac function was not damaged after the operation, and the result is more satisfactory than that of arteriovenous reversal by stages.     

Nonradiographic assessment of enteral feeding tube position

OBJECTIVE: To determine whether a clinical, nonradiographic criterion can be used to predict when the tip of a blindly placed feeding tube is in the small intestine. DESIGN: Prospective sample. SETTING: Pediatric intensive care unit at a tertiary care children's hospital. PATIENTS: Critically ill children requiring transpyloric feeding. INTERVENTIONS: The small bowel was intubated, using a blind, bedside transpyloric feeding tube placement protocol. The feeding tube was considered to be in the small bowel when <2 mL of a 10- mL aliquot of insufflated air could be aspirated from the feeding tube. This clinical criterion was confirmed with an abdominal radiograph. MEASUREMENTS AND MAIN RESULTS: Patient age ranged from 1 month to 19 yrs (median 6 months). Weight ranged from 2.2 to 60 kg (median 4.9). Median time to feeding tube placement was 10 mins (range 5 to 60). Eighty-nine percent of the patients were mechanically ventilated, while 28% of these patients were pharmacologically paralyzed. Seventy-five feeding tubes were inserted. There were no known complications. Ninety-nine (74/75) percent of the feeding tubes were positioned in the small bowel. The inability to aspirate insufflated air correctly predicted small bowel intubation with 99% certainty (Sequential Probability Ratio Test, p = .05 and power = .80). This test incorrectly predicted the position of only one feeding tube, the 26th, which was in the stomach. Of the 74 feeding tubes positioned in the small bowel, 13 feeding tubes were in the duodenum and 61 were in the jejunum. CONCLUSIONS: The inability to aspirate insufflated air confirms the transpyloric position of a feeding tube. Other clinical criteria did not successfully predict small bowel intubation. Use of this single test may obviate confirmatory abdominal radiographs in carefully selected patients and may lead to more cost-effective and timely initiation of enteral feedings.     

Early extubation following cardiac surgery in a veterans population

BACKGROUND: Early tracheal extubation is an important component of the "fast track" cardiac surgery pathway. Factors associated with time to extubation in the Department of Veterans Affairs (DVA) population are unknown. The authors determined associations of preoperative risk and intraoperative clinical process variables with time to extubation in this population. METHODS: Three hundred four consecutive patients undergoing coronary artery bypass graft, valve surgery, or both on a fast track clinical pathway between October 1, 1993 and September 30, 1995 at a university-affiliated DVA medical center were studied retrospectively. After univariate screening of a battery of preoperative risk and intraoperative clinical process variables, stepwise logistic regression was used to determine associations with tracheal extubation < or = 10 h (early) or > 10 h (late) after surgery. Postoperative lengths of stay, complications, and 30-day and 6-month mortality rates were compared between the two groups. RESULTS: One hundred forty-six patients (48.3%) were extubated early; one patient required emergent reintubation (0.7%). Of the preoperative risk variables considered, only age (odds ratio, 1.80 per 10-yr increment) and preoperative intraaortic balloon pump (odds ratio, 7.88) were multivariately associated with time to extubation (model R) ("late" association is indicated by an odds ratio >1.00; "early" association is indicated by an odds ratio <1.00). Entry of these risk variables into a second regression model, followed by univariately significant intraoperative clinical process variables, yielded the following associations (model R-P): age (odds ratio, 1.86 per 10-yr increment), sufentanil dose (odds ratio, 1.54 per 1-microg/kg increment), major inotrope use (odds ratio, 5.73), platelet transfusion (odds ratio, 10.03), use of an arterial graft (odds ratio, 0.32), and fentanyl dose (odds ratio, 1.45 per 10-microg/kg increment). Time of arrival in the intensive care unit after surgery was also significant (odds ratio, 1.42 per 1-h increment). Intraoperative clinical process variables added significantly to model performance (P < 0.001 by the likelihood ratio test). CONCLUSIONS: In this population, early tracheal extubation was accomplished in 48% of patients. Intraoperative clinical process variables are important factors to be considered in the timing of postoperative extubation after fast track cardiac surgery.     

Quantitative changes in platelet counts following major urological pelvic surgery

From 1986 to 1990, a multicentric phase II study was conducted with pirarubicin, a new semi-synthetic anthracyclin[4'-O-tetrahydropyranyl-adriamycin (THP)]. 87 patients with advanced gynaecological cancers were treated: epidermoid cervical carcinoma (n = 31), adenocarcinoma of the endometrium (n = 28) and ovarian adenocarcinoma (n = 28). THP was administered by short intravenous infusion, for 3 consecutive days, every 3 weeks. The initial dose of THP was 25 mg/m2 day (25% of patients) which was then reduced to 20 mg/m2 day. The average number of courses was 3.7 (range 1-10). The cumulative THP dose was 180 mg/m2 (range 56-594) in cervix and endometrial tumours and 121 mg/m2 (range 58-425) in ovarian tumours. Myelosuppression was the major observed toxicity with grade 3-4 leukopenia and thrombocytopenia in 62 and 19% of the patients, respectively. Severe general complications occurred in 6% of the patients with three fatalities due to infections. Gastro-intestinal side-effects were frequent and usually mild (7% of grade 3 vomiting). 48% of the patients showed alopecia, which was complete in 9 cases (10%). 3 patients experienced cardiac events. No significant antitumoral activity was observed in patients who had failed to respond to previous chemotherapy. Promising antitumoral activity was noticed in untreated cervico-uterine carcinomas with 19% partial responses and 12% complete responses (CR). THP activity was lower in endometrial carcinomas (9.5% CR). Results were found to be negligible in ovarian cancer patients, most of them being refractory to previous chemotherapy containing an anthracyclin compound. On the basis of these results, the definite role of THP in gynaecological cancers deserves to be studied in more favourable programmes (e.g. in combined protocols as first-line chemotherapy).     

Preoperative evaluation and postoperative care of the elderly patient undergoing major surgery

As the population ages and as surgical and anesthetic techniques advance, more and more elderly patients are referred for surgery. As a result, the physician must be increasingly aware of the aged response to surgery and the management of the geriatric surgical patient in the perioperative period. Elderly patients are prone to cardiac, respiratory, and infectious complications, and thus, they need to be screened for the presence of pre-existing disease. In addition, the geriatric patient needs to be carefully monitored in the proper postoperative environment to guard against untoward sequelae.     

Decisions about enteral tube feeding among the elderly

OBJECTIVE: To characterize the acute actions and physiologic dose profile of epinephrine, as a single inotrope, in patients with septic shock. DESIGN: Prospective clinical study. The relationship between epinephrine dose and cardiovascular variables was analyzed using repeated-measures analysis of variance. SETTING: ICU in a university teaching hospital. PATIENTS: Eighteen patients with septic shock, mean age 64 +/- 8 (SD) yrs, and with a mean admission Acute Physiology and Chronic Health Evaluation (APACHE II) score of 23 (range 14 to 35). INTERVENTIONS: Initial volume loading and the measurement of a baseline hemodynamic profile were followed by the administration of an epinephrine infusion at 3 microgram/min with subsequent increments of 3 micrograms/min and the determination of a hemodynamic profile after each dose increment. Therapy was titrated to clinical goals of perfusion and restoration of premorbid systolic arterial BP. MEASUREMENTS AND MAIN RESULTS: After volume loading, mean hemodynamic indices were as follows: mean arterial pressure (MAP) 62 +/- 7 mm Hg; cardiac index 3.8 +/- 1.1 L/min/m2; left ventricular stroke work index 25 +/- 11 g.m/m2; oxygen delivery (Do2) index 460 +/- 168 mL/min/m2; and oxygen consumption (VO2) index 165 +/- 64 mL/min/m2. In the dose range of 3 to 18 microgram/min, epinephrine produced linear increases in average heart rate, MAP, cardiac index, left ventricular stroke work index, stroke volume index, VO2, and DO2. No effect was noted on pulmonary artery occlusion pressure (PAOP), mean pulmonary arterial pressure, or systemic vascular resistance index. CONCLUSIONS: Epinephrine increases DO2 in septic shock by increasing cardiac index without an effect on systemic vascular resistance index or PAOP.     

Ethical issues in instituting and discontinuing enteral feeding

The authors present the results of a study to determine the serological prevalence of the enzootic bovine leukosis virus among dairy cows in the Sabana de Bogotá region and the Ubaté and Chiquinquirá Valleys, the principal dairying areas of Colombia. Samples were taken from 919 animals selected at random from 420 farms in 51 municipalities, in accordance with a statistical sampling procedure developed previously, based on the cattle census maintained by the Animal Health and Disease Control Office of the Instituto Colombiano Agropecuario, and the recommendations for prevalence studies of the Pan American Health Organization. The double gel diffusion technique with gp-51 antigen was used. Serological prevalence averaged 45.28% (ranging from 42.07% to 48.49%) with a confidence level of 95%. In addition, a survey was conducted to determine how much those in charge of herds knew about the disease, and to establish the incidence of certain risk factors possibly associated with distribution of the causal agent. Data obtained from 232 completed questionnaires showed that only 54.6% of farms received professional assistance. Of these, 6.6% received constant assistance, 4.4% received visits every fortnight, 51.8% received monthly visits, 14% received visits every other month and 22.95% received occasional visits.     

Complications of upper gastrointestinal endoscopy

Complications of upper gastrointestinal endoscopy are uncommon. Approximately one complication occurs with every 1000 procedures. The mortality rate is estimated to be between 0.5 and 3 per 10,000 cases. Cardiopulmonary events comprise 50% of all major complications, and most of these events result from the medications used for conscious sedation. Diagnosis, treatment, and prevention of common complications are discussed; rare complications are mentioned.     

A quasi-experimental study on the effect of upper gastrointestinal surgery on liver function tests

BACKGROUND/AIMS: To determine the effect of upper gastrointestinal (UGI) surgery on liver function tests, a study was performed at Loghman Hakim Hospital, Tehran, Iran. METHODOLOGY: In this quasi-experimental study, 60 patients undergoing UGI operations were compared to 20 patients with extra-abdominal surgery. In each case, after obtaining a thorough past medical history and physical exam, 5 ml of fasting venous blood was drawn pre-operatively on the morning of the operation, and liver function tests (LFTs), namely serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvic transaminase (SGPT) and lactate dehydrogenase (LDH), were measured. The three tests were repeated on the morning of days 2 and 4, post-operatively. Other intra- and post-operative parameters were also recorded. Finally, the results were analyzed in all 80 cases using the Student's t-test, Yate's corrected chi-square and Pearson's coefficient of correlation. RESULTS: The operations performed in the case group were biliary tract operations (75%), surgery on the esophagus and stomach (18.3%) and liver and pancreas operations (6.7%). The control operations consisted of head and neck surgery (45%), breast and thorax operations (35%) and prostate and testes surgery (20%). The mean duration of general anesthesia in the cases and controls was 3.62 and 3.58 hours, respectively, with no statistically significant difference. The SGOT level increased 54% in the study cases on day 2, which significantly differed with the 9% increase in the controls (p<0.05). In the cases studied, SGPT increased 65% on day 2 and 50% on day 4, with a significant difference compared to the 2% decrease and 2% increase on days 2 and 4 in the controls (p<0.005 and p<0.02, respectively). LDH levels also increased 17% on day 2 in the case group with a significant difference compared to the 8% increase in controls (p<0.05). CONCLUSIONS: An increase in the levels of SGOT, SGPT and LDH in the first 4 days following UGI surgery is a common problem which seems to be due to local trauma to the liver rather than the effect of other factors such as anesthetic drugs, the duration of surgery, blood transfusions, hypotension and other underlying conditions.