2. Critical Care
Patients needing ITU care
Emergency
Multiple trauma (including burns)
Leaking AAA
Severe acute pancreatitis
Post-operative complications:
- Surgical
- Cardiac
- Respiratory
- Renal
Severe spesis
Elective
Major vascular eg, AAA
Oesophagectomy
Cardiac operations
Major procedures
- Whipple’s
- Patients in ASA 2 category or
more
3. Critical Care
Indications for ICU transfer
Potential incipient or actual organ failure in a remediable condition
Advanced monitoring of organ function
Treatment of organ failure:
Heart – use of inotropes
Lungs – ventilation
Kidneys – renal replacement therapy
A need for 1:1 nursing
4. Critical Care
Tools for critical care
Respiratory
Pulse oximetry
- O2 saturation of arterial blood
Capnography
- CO2 tension in expired gas
Cardiovascular
Arterial lines
CVP
Pulmonary artery
flotation catheter
(PAFC)
Cardiac output
measurement
6. Critical Care
Pulse oximetry
Gives estimate of percentage saturation of
oxygen binding sites
Related to Pa02 by oxygen dissociation
curve
7. Capnography
Infra-red absorption through gas stream
Relies on rapid equilibration of CO2 between
alveolus and pulmonary capillary
Useful guide to PaCO2 but beware of lung
disease
Continuous measurement
Critical Care
8. Critical Care
Arterial line
Indications
Continuous BP
measurement
Access for serial
arterial blood gas
analysis
Complications
Bleeding
Thrombosis
Infection
Pseudoaneurysm
Accidental drug
injection
Site the line in the radial artery of the non-dominant hand. Allen’s test should be
performed.
9. Critical Care
Arterial Line
Allen’s test
The fist is tightly clenched, both wrist pulses are
tightly obstructed and the fist then released.
Pressure is released from the ulnar artery first.
Allen’s test is positive when the medial part of the
hand remains blanched.
10. Critical Care
Central venous catheterisation
Indications
Invasive monitoring for estimation of fluid status and right heart function
Long term infusions: TPN, chemotherapy
Haemodialysis
Lack of peripheral venous access
Access for pulmonary artery catheterisation
11. Critical Care
Central venous catheterisation
Complications
Inadvertent - arterial puncture
- thoracic duct puncture
- lung puncture
Air embolus
Catheter-related sepsis
Clot formation
Malposition and rupture of vein
12. Critical Care
Pulmonary artery wedge pressure
(PWAP)
It is an accurate representation of the left
atrial pressure which closely parallels the
left ventricular end-diastolic pressure thus
helping to guide fluid therapy.
13. Critical Care
Pulmonary artery wedge pressure
Introduced in 1970s by two cardiologists, Drs Swan
and Ganz. Used to measure:
Pressure within the pulmonary artery
Pulmonary artery wedge pressure
Cardiac output by thermodilution or dye dilution
method
Sampling of mixed venous blood
14. Critical Care
Pulmonary artery catheterisation
Indications
Complex operations in patients with complex
cardiopulmonary disease
Multisystem failure
Major trauma
Sepsis
Situations where accurate haemodynamic status needs to be
ascertained
15. Critical Care
Pulmonary artery wedge pressure
Complications
Valvular damage
Ventricular rupture
Pulmonary artery rupture
Aneurysm or infarction
Those of central venous catheterisation
16. Critical Care
Standard values
Central venous pressure (CVP): 0-6 mm Hg
Right ventricular pressure: 25 mm Hg
Pulmonary artery pressure (PAP): 25 mm Hg
Wedge pressure (PAWP): 6-12 mm Hg
Cardiac index (CI): >2.8-3.6 L / min / m2
Systemic vascular resistance(SVR):770-1500 dynes / sec / cm2
Oxygen delivery: 600ml / min / m2
Oxygen consumption: 150 mls / min / m2
17. Critical Care
A 60 year old man had a right
hemicolectomy. On the 1st postoperative
day he has developed a temperature of 390
C, is very short of breath and looks slightly
cyanosed; his oxygen saturation is 92%.
What will you suspect and how will you
manage the condition?
18. Critical Care
Postoperative pulmonary collapse
Although atelectasis and collapse are often
used synonymously, atelectasis strictly
speaking refers to lung parenchyma that
has never been expanded.
19. Critical Care
Postoperative pulmonary collapse
Clinical features
Tachypnoea
Pyrexia
Productive cough
Cyanosis
Dullness on percussion
Bronchial breathing
20. Critical Care
Postoperative pulmonary collapse
Management
Antibiotic – amoxycillin
O2 therapy with inspired O2 concentration of 30-40% with
humidification
Vigorous physiotherapy + / - iv Doxapram
Urgent fibreoptic bronchoscopy
Minitracheostomy
Continue with physiotherapy and monitor with blood gases and
pulse oximetry- aim for oxygen tension to be no less than 10kPa
21. Critical Care
Postoperative pulmonary collapse
This arises from reduced ventilation of the lung bases
resulting in accumulation of bronchial secretions. This may
be basal, segmental, lobar or complete lung collapse. The
degree of hypoxia depends upon the extent of collapse.
Infection with consolidation supervenes with the organisms
being Haemophilus influenza, streptococcus pneumoniae,
coliform, MRSA and pseudomonas.
22. Critical Care
Post-operative hypoxia
Surgical patients at risk of hypoxia
Smokers
Chronic pulmonary disease
Elderly
Obesity
Pre-operative opiates and sedatives
Abdominal emergency surgery
Orthopaedic surgery (fat emboli)
23. Critical Care
Effects of post-operative hypoxia
Central nervous system
- Obtunded pain sensation
- Post-operative confusion
Cardiovascular system
- Tachycardia
- Myocardial ischaemia
Respiratory system
- Hypercapnoea (airway obstruction)
- Respiratory muscle failure
Renal - Renal failure
24. Critical Care
Effects of post-operative hypoxia (contd)
Gastrointestinal - Ulceration
- Reduced immunoprotection
Hepatic - Ischaemic necrosis of hepatocytes
Haematological - Reduced platelet function
- Coagulation problems
Wound healing - Impaired wound healing
25. Critical Care
Respiratory failure
Respiratory failure is defined as an
arterial oxygen tension (PaO2) at sea
level of less than 8 kPa, i.e. hypoxia
due inadequate gas exchange within
the lung.
28. Critical Care
A 65 year old lady had a hip replacement 10
days ago. She is ready to be discharged.
She went to the toilet just prior to leaving
the ward for home. She collapsed in the
toilet. What is your diagnosis and
management?
39. Critical Care
A 60 year old patient of ASA 1 anaesthetic
risk underwent a total gastrectomy for
cancer stomach. While in the ITU, 12 hours
postoperatively, his BP has fallen to 80 mm
hg systolic, has not put out any urine over
the last 3 hours and is hypoxic with O2
saturation of 92%. What will you suspect
and how will you manage?
40. Critical Care
Answer
Post-operative hypotension from bleeding
Q. Where would the bleeding come from?
Slipped left gastric artery ligature
Q. Where does the left gastric artery arise from?
The coeliac axis
47. Critical Care
A 60 year old woman has been admitted as
an emergency with a 4 day history of
severe right upper quadrant pain, vomiting,
jaundice and intense pruritis and is very
toxic – high temperature with rigors and
hyperdynamic circulation. What will you
suspect and outline the management.
48. Critical Care
Septic shock from acute calculous biliary obstruction
+/- Acute pancreatitis
Management
Resuscitation
Confirmation of diagnosis
Definitive treatment
49. Critical Care
Acute calculous biliary obstruction
+
Septic shock +/- Acute pancreatitis
Resuscitation
Analgesia
IV Dextrose; Mannitol; Antibiotics after blood
culture
Urinary catheter
CVP line
51. Critical Care
Bacteraemic shock
Caused by release of endotoxins
Vasoactive substances eg, kinins released
Capillary permeability increased
Peripheral resistance decreased
Fever: hyperdynamic circulation
Treatment: O2; circulatory support; inotropes
52. Critical Care
The Septic Patient
The term SIRS is used to describe the widely
disseminated inflammatory reaction which can
complicate a wide range of disorders eg,
pancreatitis, trauma, ischaemia.
The term SEPSIS is used in those patients in
whom SIRS is associated with proven infection
55. Critical Care
Early features of sepsis
Fever or hypothermia
Leucocytosis or leucopenia
Tachycardia
Tachypnoea
Organ dysfunction: Brain - altered mental state
Lungs - hypoxia
Kidneys - oliguria
56. Critical Care
Nosocomial Infections
(Hospital acquired infections)
( Gk: nosokomeion )
Gk: nosos- of disease; komeo – to nurse
The patient in the ITU who has some degree of organ dysfunction is
vulnerable to nosocomial infections.
Good principles of infection control and avoidance of cross-infection
by staff
Bacteria in the GI tract of the patient is the commonest source
Nosocomial pneumonia occurs from spillage from the upper GI tract
into the lungs
H2 receptor antagonists encourages nosocomial infections
Sucralfate used as stress ulcer prophylaxis is also bacteriostatic
and thus reduces the incidence
57. Critical Care
A 70 year old patient, ASA anaesthetic category
3, underwent an emergency closure of a
perforated duodenal ulcer. The anaesthetic and
operation were uneventful. On the 1st post-
operative day he complained of feeling very
unwell with a systolic bp of 80 mm hg with no
unusual signs in his abdomen; there was impaired
conscious level and peripheral vasoconstriction.
What will go through your mind and outline your
management.
58. Critical Care
Cardiogenic shock from myocardial infarction
Patient already has a drip
ECG - ST elevation in precordial leads
- Development of new Q waves – wide & / or deep
- T wave inversion
Pulse oximeter
Blood for: CK-MB ( creatine kinase, membrane bound )
ALT ( alanine aminotransferase )
AST ( aspartate aminotransferase )
LDH ( lactic dehydrgenase )
Troponin T assay
Transfer to CCU
59. Critical Care
Cardiogenic shock from myocardial infarction
CCU management
CVP
Consider PAFC
O2 therapy
Aspirin
Nitrates, ACE inhibitors and opiates
IV beta blockers
Consider reperfusion strategy
60. Critical Care
Cardiogenic shock
Complications of MI
Cardiac arrest ( ventricular fibrillation, VF )
Pump failure
Arrhythmias
Ventricular septal defect ( VSD )
Cardiac rupture
Pericardial tamponade
Ventricular aneurysm
Mitral regurgitation
MunschC & Shah R in Handbook of Postoperative Complications .Ed Leaper DJ & Peel ALG. 2003, OUP
61. Critical Care
Cardiogenic shock
Risk of perioperative MI in the general surgical population = 0.07%
Risk of MI if surgery is performed within 3 months of MI = 25%
Risk factors
Previous MI
Unstable angina
Disabling angina
Silent ischaemia
Hypertension
MunschC & Shah R in Handbook of Postoperative Complications .Ed Leaper DJ & Peel ALG. 2003, OUP
62. Critical Care
Cardiogenic shock
Definition
Cardiogenic shock indicates a state of inadequate circulatory perfusion
caused by cardiac dysfunction.
Causes
Mycardial infarction
Cardiac arrhythmias
Tension pneumothorax
Cardiac tamponade
Vena caval obstruction
Dissecting aneurysm
65. Critical Care
A fit 30 year old lady while gardening
suddenly became very short of breath, had
intense itching with rash and complained of
a painful red spot on her arm. She has
been brought to the A&E department and is
hypotensive, hypoxic and cold. What is
your diagnosis and how will you manage?
67. Critical Care
Anaphylactic Shock
Mechanism
The antigen combines with immunoglobulin (IgE)
on the mast cells and basophils, releasing large
amounts of histamine and SRS-A (slow-release
substance-anaphylaxis). These compounds cause
the symptoms.
Mortality about 10%
68. Critical Care
A 50 year old man underwent a laparoscopic
closure of a perforated duodenal ulcer. His post-
operative period during the first 4 to 5 days was
uneventful. However, thereafter he did not
progress satisfactorily, had a swinging pyrexia,
hiccoughs, was tachypnoeic, toxic and
complained of pain in the right upper quadrant
and right shoulder tip . What would you suspect
and outline the management.
71. Critical Care
Sub-phrenic abscess
“Pus somewhere, pus nowhere, pus under the
diaphragm.”
Investigations for confirmation
Blood: Culture, FBC, CRP
CXR
Ultrasound
?CT
72. Critical Care
Sub-phrenic abscess
Treatment
US or CT guided needle drainage. This may
require more than one attempt because there may
be several loculi of the abscess.
Open operation – extra-peritoneal approach –
anterior or posterior depending upon the site
73. Critical Care
How many sub-phrenic spaces are there and what are they?
7 spaces in all
4 intra - peritoneal – 2 right and 2 left ( important ones )
3 extra - peritoneal
2 right intra-peritoneal – Right anterior ( R subdiaphragmmatic )
Right posterior (R subhepatic or Morison’s hepato-renal pouch)
2 left intra-peritoneal – Left anterior ( L subdiaphragmmatic )
Left posterior ( L subhepatic or lesser sac or omental bursa )
3 extra-peritoneal – 2 around the upper pole of each kidney and 1
over bare area of liver
The extra-peritoneal spaces are not clinically important.
Rarely the bare area of the liver may be involved in a liver abscess from amoebic infection.
74. Critical Care
The Septic Patient
Investigations
Blood cultures
U&Es, FBC, CRP, Clotting studies, LFTs
CXR
Appropriate imaging studies for source
75. Critical Care
The Septic Patient
Management
Supportive measures:
- Oxgenation
- Ventilation if necessary
- IV fluids
- Inotropic support
- Nutritional support
Specific measures
- Antibiotics
- Drainage
76. Critical Care
A 70 year old man underwent emergency
operation for a leaking AAA. While in the
ITU, after 2 days, he became oliguric, has
abdominal distension and cardio-
respiratory compromise. His CVP is 10 cm
of water. He is still on the ventilator. What
will you suspect and how will you manage?
77. Abdominal Compartment Syndrome
This is a condition in which there is a
sustained increase in intra-abdominal
pressure resulting in inadequate ventilation
from type 2 respiratory failure, disturbed
cardiovascular and renal function.
79. Abdominal Compartment Syndrome
Aetiology
Blunt and penetrating abdominal trauma with liver, vascular and
splenic damage
More likely after abdominal and pelvic trauma
Risk increases with increase in Injury Severity Score
Repair of AAA (Emergency or Elective) – 3.8% after repair of
ruptured AAA
Burns – should be suspected as a cause for renal failure inspite of
adequate fluid resuscitation
80. Abdominal Compartment Syndrome
Diagnosis
Patients usually in ICU
Tense abdomen
Cardio-respiratory compromise in the absence of
hypovolaemia
Renal failure
Round belly sign ( Ratio of AP to transverse
abdominal diameter > 0.80 )
82. Abdominal Compartment Syndrome
Pressures
Measure intra-abdominal pressure (IAP) with a catheter directly into
peritoneal cavity
Transurethral bladder pressure reflects IAP – most commonly used
Normal IAP: Men: 3.5 - 10.5 mm hg
Women: 3.0 - 8.8 mm hg
IAP . 15 – 25 mm hg is diagnostic
83. Abdominal Compartment Syndrome
Treatment
Decompression
Leave abdomen open and cover temporarily with mesh, plastic bag
fascial closure, plastic or silicone sheet or vacuum pack
Mortality: 63 – 72%
Ventral hernia: 63%
84.
85. Critical Care
A 77 year old man underwent a TURP. On
the 2nd post-operative day he is confused,
restless and has some visual disturbance.
What will you suspect and how will you
manage?
86. Critical Care
Post TURP syndrome
( Dilutional hyponatraemia)
Clinical features
Restlessness, muscle twitching,
disorientation, visual disturbances, seizures
& collapse
Hypertension, severe hyponatraemia
87. Critical Care
Post TURP syndrome
Cause
Occurs following prolonged prostatic resection of
large glands and likely when more than 9 L of
glycine (1.5%) irrigation is used. Large volume of
irrigating fluid enters the vascular space causing
dilutional hyponatraemia resulting in disturbance
of muscle and nerve function.
88. Critical Care
Post TURP syndrome
Treatment
Needs ITU monitoring – CVP, serum osmolality,
serum Na
Supportive
Frusemide
Hypertonic saline through CVP line (250-500 mls
of 3 to 5 %) when there are seizures
89. Caritical Care
Post TURP syndrome
Prevention
Keep level of irrigating fluid below 20cm above
the operating table
Stop resection if large veins are opened
Use irrigating resectoscope
IV normal saline postoperatively for 12 hours
90. Critical Care
A 60 year old man underwent a Whipple’s
operation for periampullary carcinoma. On
the 2nd postoperative day, while still in the
ITU, his urinary output has reduced to 300
mls in the previous 12 hours. The catheter
is not blocked. What will you suspect and
how will you manage?
91. Critical Care
Hepato-renal syndrome
Can occur following an operation in a patient with
obstructive jaundice
Reduced GFR – not known why
Circulating endotoxins - endotoxinaemia
Absorption of endotoxin produced by the intestinal
microflora
In the jaundiced patient there is a relationship between impaired
renal function and the presence of circulating endotoxins
Cuschieri A, Steele RJC & Moosa AR: Essential Surgical Practice – HST in General Surgery 2002; 401
92. Critical Care
Hepato-renal syndrome
Prevention
Adequate hydration and pre-operative induction of diuresis
For 12 - 24 hours pre-operative 5% dextrose saline iv
Mannitol (osmotic diuretic) or Frusemide (loop diuretic) iv at
anaesthetic induction
Catheterise - hourly urine output
Further diuretics if urine output < 40ml/hr in peri-operative and post-
operative period
Pre-operative oral chenodeoxycholate and oral lactulose for a few
days – controversial
Cuschieri A, Steele RJC & Moosa AR: Essential Surgical Practice – HST in General Surgery 2002; 401
94. Critical Care
Renal failure
Treatment of hyperkalaemia
10 to 20 mls of10% Ca gluconate or chloride iv : stabilises the
myocardial membrane
50 mls of 50% dextrose + 10 units of soluble insulin: drives
potassium into cells
200 to 300 mls of 1.4% sodium bicarbonate iv: drives potassium
into cells and corrects acidosis; beware of fluid overload in ARF
Calcium resonium 15 g tds orally or rectally: binds potassium and
releases Ca in exchange
Renal replacement therapy
95. Critical Care
Renal failure
Predisposing causes
Preoperative renal impairment
Surgery associated with major blood loss and fluid shifts
Hypovolaemia
Hypotension
Sepsis
Nephrotoxic drugs
96.
97.
98. Critical Care
A 60 year old man underwent a successful
embolectomy of his leg. The next day he
developed severe throbbing pain in the leg
which on examination did not look
ischaemic and was warm to touch. What
would you suspect and how would you
manage the condition?
99. Critical Care
Acute limb compartment syndrome
What are the causes of this condition?
How do you diagnose it?
How do you treat the condition?
100. Acute Limb Compartment Syndromea
This is a condition in which raised pressure
within a closed fascial space reduces
capillary perfusion below a level necessary
for tissue viability.
101. Acute Limb Compartment Syndrome
Aetiology
Orthopaedic
Vascular
Iatrogenic
Soft tissue injury
Tiwari A, Haq A I, Myint F, Hamilton G: Acute compartment syndromes: Br J Surg (April) 2002, 89, 397 - 412
102.
103. Acute Limb Compartment Syndrome
Presentation
Pain – severe and out of proportion to the apparent injury
Pain on passive movement
Swollen and tense compartment
Progression of the above over a short time period
Paraesthesia – especially loss of two point discrimination
Pallor and pulselessness – usually with a vascular injury
Paralysis – late symptom
104. Acute Limb Compartment Syndrome
Pressures
Normal resting: 0 - 8 mm hg
Pain and paraesthesia: 20 – 30 mm hg
Fasciotomy: > 30 mm hg
If pressure of > 30 mm hg is present for 6 – 8 hours irreversible damage occurs
110. Critical Care
Pain relief
Post-operative pain
Diclofenac suppositories
LA to incision site
IV narcotic drugs
Regional analgesia eg, caudal block, intercostal block
Continuous epidural analgesia
Continuous IV opiate analgesia
PCA by IV or epidural opioid analgesia
111. Critical Care
Drugs for treatment of post-operative pain
Simple analgesics: Paracetamol, Aspirin
NSAIDs
Intermediate drugs: Tramadol, Co-dydramol
Opioids: Morphine, Diamorphine
Local anaesthetics: Lignocaine, Bupivacaine
112. Critical Care
Pain relief
Intractable pain
‘As doctors we are there to cure sometimes, to relieve often and to comfort always’ Sir James Calnan
Intractable pain is defined as chronic and
continuous pain where the cause cannot be
removed or the origin cannot be determined.
Causes: Benign
Malignant
113. Critical Care
Relief of Benign Intractable Pain
LA + / - steroid injections
Nerve stimulation procedures
Nerve decompression
Sympathectomy
125. Nutrition
Assessment
Body weight
Upper arm circumference : < 23cm in females, < 25 cm in
males
Triceps skinfold thickness : < 13 mm in females, < 10 mm in
males
Serum albumin : < 35 g / l
Lymphocyte count : < 1500 / c mm
Candida skin test : -ve reaction indicates defective immunity
Nitrogen balance studies
Goode A W : Nutritional support and rehabilitation in Bailey and Love, 23rd Ed, 2000
127. Nutrition
A healthy adult at rest requires 6300 – 8400
nonprotein kilojoules per day for energy
( 1500 – 2000 calories).
Goode A W : Nutritional support and rehabilitation in Bailey and Love 23rd Ed, 2000
128. Nutrition
In Burns
Give 25 kcl/kg body weight + 40 kcl / % body
surface area burnt in the adult
The child needs more calories / kg body weight
The infant needs 90 – 100 kcl / kg
Cuschieri A, Steele R J , Moosa A R : Management of the burns victim in Essential Surgical Practice,
Basic Surgical Training, 4th Ed. 2001, p 116
129. Nutrition
Requirements
Carbohydrate provides 16.8 kJ/g (4.1 kcal/g)
Fat provides 37.8 kJ/g (9.1 kcal/g)
The number of nonprotein kilojoules given should bear a definite
relationship to the nitrogen intake. A typical regime would feature
8400 kJ (2000 kcal) to 13 g nitrogen ( about 150 to 1 ).
Goode A W : Nutritional support and rehabilitation in Bailey and Love, 23rd Ed 2000
130. Nutrition
Nitrogen requirements
A healthy adult in positive nitrogen balance
needs 35-40 g of protein or 5.5 -6.5g of
nitrogen a day.The hypercatabolic patient
requiring hyperalimentation may need 3 to
4 times this amount of protein.
Goode A W: Nutritional support and rehabilitation in Bailey & Love 23rd ed
2000
132. Nutrition
Complications of enteral nutrition
Nutritional and metabolic
Complications of nutrient delivery
Gastrointestinal complications
Cuscgeri A, Steele R J C & Moosa A R :Enteral nutrition in Essential Surgical Practice, 4th Ed 2001
133. Nutrition
Methods of feeding
Parenteral
Used in < 4 – 5% of all hospital admissions
Used when enteral feeding is not possible or to
supplement enteral feeding
Indications: Short term
Long term ( HPN )
134. Nutrition
Complications of parenteral nutrition
Catheter related
Nutritional and metabolic
Effect on other organ systems
Cuscheri A, Steele R J C and Moosa A R : Parenteral nutrition in Essential Surgical Practice, 4th Ed. 2001
135. Nutrition
Complications of parenteral nutrition
Catheter related
Infection
Thrombosis
Occlusion
Fracture
Cuscheri A, Steele R J C& Moosa A R : Parenteral nutrition in Essential Surgical Practice, 4th Ed
2001
136. Nutrition
Complications of parenteral nutrition
Nutritional and metabolic
Fluid overload
Hyperglycaemia
Electrolyte imbalance
Micronutrient deficiencies eg selenium in long-term patients
Cuscheri A, Steele & Moosa A R: Parenteral nutrition in Essential Surgical Practice, 4th Ed 2001
137. Nutrition
Complications of parenteral nutrition
Effect on other organ systems
Hepatobiliary system – biliary sludge, hepatic steatosis,
cholestasis
The immune system
Skeleton – metabolic bone disease
Cuscheri A, Steele JR J C & Moosa A R : Parenteral nutrition in Essential Surgical Practice, 4thEd 2001
138. Nutrition
Monitoring feeding regimens in parenteral nutrition
Daily
Body weight
Fluid balance
FBC, U&E
Blood glucose
Urine and plasma osmolality
Electrolyte and nitrogen analysis of urine and gastrointestinal losses
Acid-base status
Goode A W : Nutritional support and rehabilitation in Bailey and Love 23rd Ed, 2000
139. Nutrition
Monitoring feeding regimens in parenteral nutrition
Every 10 days
Serum B12, Folate, Iron, lactate and triglycerides
Trace elements
Goode A W: Nutritional support and rehabilitation in Bailey & Love 23rd Ed, 2000
140. Nutrition
Monitoring feeding regimens in parenteral nutrition
Three times weekly
Serum Calcium, magnesium and phosphate
Plasma proteins
LFTs
Clotting studies
Goode A W : Nutritional support and rehabilitation in Bailey & Love, 23rd Ed 2000
