1) RT, a 59-year-old woman with a BMI of 103, underwent Roux-en-Y gastric bypass surgery and developed multiple postoperative complications including an anastomotic leak, bowel resection, and acute renal failure.
2) She required long-term parenteral nutrition due to her inability to tolerate enteral nutrition. Determining appropriate calorie and protein levels for her nutrition was challenging given her extreme obesity.
3) Over several weeks, her parenteral nutrition was adjusted based on lab results and clinical status. She eventually stabilized and was discharged on parenteral nutrition with plans to transition to enteral nutrition once her intestinal fistulas closed.
Chronic Idiopathic Constipation: Unmet Medical Need and the Role of Uroguanyl...Synergy Pharmaceuticals
- The document discusses chronic idiopathic constipation (CIC), an underserved medical condition that places a significant burden on patients and the healthcare system.
- It describes the role of guanylate cyclase-C (GC-C) receptors and their ligands, such as uroguanylin, in regulating fluid balance and motility in the intestines. Activation of GC-C receptors increases intestinal fluid secretion and motility.
- The properties of the endogenous ligands guanylin and uroguanylin, as well as the bacterial toxin STa that can activate GC-C receptors, are reviewed. Uroguanylin appears to be a more potent GC-C agonist than gu
This document discusses nutritional support for hospitalized patients. It provides guidelines for when nutritional support is indicated, including if a patient has been without nutrition for 7-10 days, the expected duration of illness is over 10 days, or the patient has lost over 15% of their usual body weight. It describes evaluating a patient's risk for aspiration before initiating enteral or parenteral nutrition. Key considerations for nutritional support include estimating caloric and protein needs based on the patient's condition and monitoring for complications.
Total enteral nutrition and total parenteral nutrition in critically ill pat...Prof. Mridul Panditrao
This document discusses total enteral and parenteral nutrition in critically ill patients. It begins by outlining normal energy and protein requirements, then discusses the prevalence and consequences of malnutrition in hospitalized patients. It describes the metabolic response to critical illness and trauma as having an "ebb phase" and "flow phase". The document advocates for early initiation of nutritional support via the enteral route when possible using techniques like post-pyloric feeding tubes, but notes total parenteral nutrition may be needed if enteral nutrition is not tolerated. It provides guidelines on calculating protein and calorie needs and discusses considerations, benefits, risks and protocols for both enteral and parenteral nutrition.
Importance of nutritional management during hospitalizationBushra Tariq
The document discusses the importance of nutritional management for hospitalized patients. It notes that up to 50% of hospitalized patients experience some degree of malnutrition. Providing adequate nutrition support through enteral or parenteral nutrition can improve patient outcomes, reduce recovery time, and lower healthcare costs. The document provides guidelines for estimating caloric and protein needs for critically ill patients and recommends early enteral nutrition within 24-48 hours when possible to support gut health and integrity.
This document discusses various nutrition guidelines and pyramids over time including the USDA pyramid from 1992, the new Portuguese wheel from 2003, and the Harvard School of Public Health pyramid from 2005. It also discusses various diets such as vegetarian, Mediterranean, and Latin American pyramids. The document notes controversies around nutrition recommendations that are based on legends and epidemiology rather than rigorous clinical trials. It questions recommendations for limiting dietary cholesterol to below 300 mg/day given studies showing minimal effects of cholesterol intake on LDL levels.
Nutritional depletion is common in hospitalized patients, especially the elderly. While enteral nutrition is preferred when possible, total parenteral nutrition (TPN) is an option but provides no survival benefit and increased complications. For patients who can eat, balanced meals should be provided with assistance as needed. A percutaneous endoscopic gastrostomy (PEG) tube may be considered for long-term enteral feeding over 1 month but outcomes are unclear in advanced dementia, so alternative strategies like hand feeding should be discussed.
Revisional bariatric surgery rates are increasing as more primary bariatric surgeries are performed. Common causes of failure include non-compliance with lifestyle changes and weight regain. Evaluation of failed patients includes assessing compliance and reviewing anatomy with imaging and endoscopy. Revisional options depend on the cause of failure and may include converting to Roux-en-Y gastric bypass, sleeve gastrectomy, or adding a gastric band. Outcomes of revisional surgery show around a 50% excess weight loss with some increased risks of complications compared to primary surgery. Careful patient selection and counseling are important for success.
Chronic Idiopathic Constipation: Unmet Medical Need and the Role of Uroguanyl...Synergy Pharmaceuticals
- The document discusses chronic idiopathic constipation (CIC), an underserved medical condition that places a significant burden on patients and the healthcare system.
- It describes the role of guanylate cyclase-C (GC-C) receptors and their ligands, such as uroguanylin, in regulating fluid balance and motility in the intestines. Activation of GC-C receptors increases intestinal fluid secretion and motility.
- The properties of the endogenous ligands guanylin and uroguanylin, as well as the bacterial toxin STa that can activate GC-C receptors, are reviewed. Uroguanylin appears to be a more potent GC-C agonist than gu
This document discusses nutritional support for hospitalized patients. It provides guidelines for when nutritional support is indicated, including if a patient has been without nutrition for 7-10 days, the expected duration of illness is over 10 days, or the patient has lost over 15% of their usual body weight. It describes evaluating a patient's risk for aspiration before initiating enteral or parenteral nutrition. Key considerations for nutritional support include estimating caloric and protein needs based on the patient's condition and monitoring for complications.
Total enteral nutrition and total parenteral nutrition in critically ill pat...Prof. Mridul Panditrao
This document discusses total enteral and parenteral nutrition in critically ill patients. It begins by outlining normal energy and protein requirements, then discusses the prevalence and consequences of malnutrition in hospitalized patients. It describes the metabolic response to critical illness and trauma as having an "ebb phase" and "flow phase". The document advocates for early initiation of nutritional support via the enteral route when possible using techniques like post-pyloric feeding tubes, but notes total parenteral nutrition may be needed if enteral nutrition is not tolerated. It provides guidelines on calculating protein and calorie needs and discusses considerations, benefits, risks and protocols for both enteral and parenteral nutrition.
Importance of nutritional management during hospitalizationBushra Tariq
The document discusses the importance of nutritional management for hospitalized patients. It notes that up to 50% of hospitalized patients experience some degree of malnutrition. Providing adequate nutrition support through enteral or parenteral nutrition can improve patient outcomes, reduce recovery time, and lower healthcare costs. The document provides guidelines for estimating caloric and protein needs for critically ill patients and recommends early enteral nutrition within 24-48 hours when possible to support gut health and integrity.
This document discusses various nutrition guidelines and pyramids over time including the USDA pyramid from 1992, the new Portuguese wheel from 2003, and the Harvard School of Public Health pyramid from 2005. It also discusses various diets such as vegetarian, Mediterranean, and Latin American pyramids. The document notes controversies around nutrition recommendations that are based on legends and epidemiology rather than rigorous clinical trials. It questions recommendations for limiting dietary cholesterol to below 300 mg/day given studies showing minimal effects of cholesterol intake on LDL levels.
Nutritional depletion is common in hospitalized patients, especially the elderly. While enteral nutrition is preferred when possible, total parenteral nutrition (TPN) is an option but provides no survival benefit and increased complications. For patients who can eat, balanced meals should be provided with assistance as needed. A percutaneous endoscopic gastrostomy (PEG) tube may be considered for long-term enteral feeding over 1 month but outcomes are unclear in advanced dementia, so alternative strategies like hand feeding should be discussed.
Revisional bariatric surgery rates are increasing as more primary bariatric surgeries are performed. Common causes of failure include non-compliance with lifestyle changes and weight regain. Evaluation of failed patients includes assessing compliance and reviewing anatomy with imaging and endoscopy. Revisional options depend on the cause of failure and may include converting to Roux-en-Y gastric bypass, sleeve gastrectomy, or adding a gastric band. Outcomes of revisional surgery show around a 50% excess weight loss with some increased risks of complications compared to primary surgery. Careful patient selection and counseling are important for success.
This document discusses nutritional support for ICU patients. It begins with a brief history of ICU nutrition and outlines the basis for nutritional support. Providing nutrition is important to prevent the physiologic effects of malnutrition, which can lead to organ dysfunction and poor outcomes. The nutritional requirements of ICU patients, including calories, protein, fluids and micronutrients are described. Enteral and parenteral routes of feeding administration are covered, along with their indications. Guidelines for initiating feeding, monitoring for complications, and calculating nutritional needs are provided. The goal of nutritional support is to improve patient outcomes by preventing and treating critical illness-related malnutrition.
This document provides information on a 40-year-old female patient admitted for J-tube placement due to severe protein-energy malnutrition. She has a complex surgical history including gastrectomy and small bowel resections which has resulted in nutritional deficiencies. Laboratory results show low albumin, prealbumin, calcium and magnesium levels indicative of her malnutrition. The patient is started on continuous tube feedings which are advanced gradually, however her blood sugars remain difficult to control when eating orally in addition to the tube feedings.
This document provides a nutrition assessment and medical nutrition therapy plan for a 63-year-old male patient who underwent a laryngectomy, pharyngectomy, esophagectomy with gastric pull-up followed by radiation for squamous cell carcinoma. The registered dietitian found the patient to be at high nutritional risk due to a 23 pound unintended weight loss over the past year and being 79% of his ideal body weight at the time of surgery. The initial plan was to start enteral nutrition via tube feeding post-operatively. Follow-up notes document the patient tolerating the tube feeding well with some loose stools. The plan was adjusted to a fiber-containing formula and supplements to address this. The registered diet
This document discusses nutritional support for patients in the intensive care unit (ICU). It covers reasons for nutritional support like limiting catabolism and increasing survival. It describes assessing patients and calculating calorie and protein needs using formulas like Harris-Benedict and Ireton-Jones. Enteral nutrition is preferred over total parenteral nutrition when possible due to lower infection risks. Early enteral nutrition within 24-48 hours is associated with better outcomes. Overfeeding can cause complications so goals are tailored to patient stress level and condition.
This case study describes a 57-year-old male admitted to the hospital with nausea, vomiting, abdominal pain, jaundice, ascites, and black stools. He was diagnosed with GERD, gastrointestinal bleeding, and cirrhosis. During his hospital stay, he received various treatments including tube feeding and TPN. His condition deteriorated and he was transferred to the ICU. He later stabilized and was transitioned to an oral diet to prepare for discharge with diagnoses of chronic cirrhosis, GERD, and esophageal varices.
Medical nutrition therapy status post whipple procedureValerie Agyeman
SG, a 72-year-old female, underwent a Whipple procedure for pancreatic adenocarcinoma. She experienced significant weight loss pre-operatively and nutritional complications post-operatively including delayed gastric emptying and electrolyte abnormalities. The registered dietitian's nutrition diagnoses included malnutrition, unintentional weight loss, and altered GI function. The RD prescribed a carbohydrate-controlled diet and thickened liquids, provided nutrition education, and collaborated with other providers to optimize SG's recovery.
This document discusses nutrition in critically ill patients. It covers nutritional assessment, calculating caloric and protein requirements, and options for nutritional support including enteral and parenteral nutrition. The key points are that enteral nutrition is preferred when possible as it is more physiologic and protects gut function, and nutrition should be started early in critically ill patients to prevent catabolism and support recovery. Contraindications and complications of enteral feeding are also reviewed.
Daily minimum nutritional requirements of the critically illRalekeOkoye
The document discusses the daily minimum nutritional needs of critically ill patients. It defines key terms like critically ill patient and malnutrition. It describes the nutritional changes, assessment of nutritional state, and predictors of outcome during critical illness. It provides guidelines for calculating nutritional requirements including carbohydrates, proteins, fats, vitamins, and minerals. It discusses enteral nutrition as the preferred route of administration when possible, and provides guidelines for safe enteral feeding including early initiation and proper tube positioning.
This ppt gives you an idea of Citrulline-a naturally occuring basic amino acid, its structure, its role as marker, its uses, its clinical importance,etc.
A 57-year-old male was admitted with nausea, vomiting and abdominal pain due to cirrhosis and bleeding esophageal varices. He has a history of alcoholism. Initial labs showed hyponatremia and low albumin. A jejunostomy tube was placed for nutrition but caused intolerance. He was started on TPN with Hepatamine which was later tapered as he transitioned to an oral soft diet.
The document discusses the basis of nutritional support for critically ill patients, outlining factors that can lead to malnutrition in intensive care and the consequences of malnutrition. It covers methods for assessing nutritional status and determining nutritional requirements. Guidelines are provided on enteral and parenteral nutrition support based on a patient's condition and clinical setting.
A 57-year-old male with a history of alcoholism and cirrhosis was admitted with upper GI bleeding and black stools. Evaluation found esophageal varices and laboratory abnormalities including low sodium and albumin. He was started on medications and tube feeding but developed intolerance. A TPN was started but also not well tolerated. He was placed on a soft diet low in sodium as he prepared for discharge with a diagnosis of chronic alcoholic cirrhosis and esophageal varices.
Cystic Fibrosis Nutritional Case Study PresentationMary Rodavich
The document discusses cystic fibrosis and cystic fibrosis-related diabetes (CFRD), outlining their causes, symptoms, and treatment, including medical nutrition therapy. It also provides details of a specific 24-year-old female patient's history and condition, including her diagnosis of CFRD, and outlines her nutrition assessment, diagnosis, and prescribed nutrition interventions and monitoring.
The document discusses parenteral and enteral nutrition for critically ill patients. It recommends early enteral nutrition within 48 hours for critically ill patients without contraindications to reduce infections and mortality. For patients who cannot tolerate enteral nutrition, initiating parenteral nutrition within the first few days may be considered for malnourished patients, though the effects are unknown. The complications, formulations, administration methods, and monitoring of both enteral and parenteral nutrition are also covered.
This patient was admitted with symptoms of nausea, vomiting, abdominal pain and black stools. He has a history of hypertension, gallbladder removal and GERD. Diagnosis includes GERD, GI bleeding and cirrhosis of the liver. A jejunostomy tube was placed for nutrition due to malabsorption from liver disease. The patient was started on TPN and stabilized. TPN was tapered and the patient advanced to a clear liquid diet and then oral diet as tolerated. He was discharged on a soft diet restricted to 2000ml fluids per day with sodium and protein recommendations.
Type 2 diabetes has traditionally been viewed as a progressive disease requiring increasingly intensive treatment over time. However, recent evidence shows that type 2 diabetes is fully reversible through substantial weight loss induced by bariatric surgery or low-calorie diets. Within weeks of such interventions, fasting glucose levels can normalize as liver fat is reduced and hepatic insulin sensitivity improves. Over months, pancreatic fat depletion leads to the full restoration of beta cell function. This demonstrates that type 2 diabetes is caused by excess fat in metabolic organs and is a potentially reversible condition through weight loss and improved metabolic health.
Obesidad: nutrientes moduladores de neuropeptidos y neurotransmisoresNutriline SRL
This document discusses ketogenic enteral nutrition (KEN) as a treatment for obesity. It describes a study of over 19,000 obese patients who underwent 10-day cycles of receiving 50-65 grams of protein per day via continuous nasogastric tube infusion, without any carbohydrates. This protocol resulted in an average weight loss of 10.2 kg over 2.5 cycles, with 57% of the loss being fat mass. No significant adverse effects occurred. KEN is concluded to be a safe, fast, and inexpensive treatment that provides good long-term weight maintenance results.
This study examined how appetite, as measured by visual analog scales (VAS), is affected by weight loss through energy restriction and a low-fat diet/exercise program. Seventeen subjects participated in a 15-week weight loss program involving energy restriction followed by an 18-week low-fat diet and exercise phase. Appetite was measured using VAS before and after a standardized breakfast. Fasting cortisol, leptin, glucose and insulin were also analyzed. The study found that fasting appetite increased after both phases of weight loss. Changes in fasting cortisol best predicted changes in appetite, particularly for men. The results suggest that weight loss is accompanied by an increase in baseline appetite and that changes in fasting cortisol are the
1) The patient is a 53-year-old woman seeking pharmacotherapy for weight loss in addition to lifestyle modifications. She has a history of anxiety treated with paroxetine and past narcotic abuse.
2) Orlistat is recommended as it inhibits fat absorption and has beneficial effects on lipids, important for this patient with dyslipidemia.
3) Lorcaserin is not recommended due to potential interaction with paroxetine. Phentermine is not recommended due to risk of addiction given her history of abuse.
This document discusses nutritional support for ICU patients. It begins with a brief history of ICU nutrition and outlines the basis for nutritional support. Providing nutrition is important to prevent the physiologic effects of malnutrition, which can lead to organ dysfunction and poor outcomes. The nutritional requirements of ICU patients, including calories, protein, fluids and micronutrients are described. Enteral and parenteral routes of feeding administration are covered, along with their indications. Guidelines for initiating feeding, monitoring for complications, and calculating nutritional needs are provided. The goal of nutritional support is to improve patient outcomes by preventing and treating critical illness-related malnutrition.
This document provides information on a 40-year-old female patient admitted for J-tube placement due to severe protein-energy malnutrition. She has a complex surgical history including gastrectomy and small bowel resections which has resulted in nutritional deficiencies. Laboratory results show low albumin, prealbumin, calcium and magnesium levels indicative of her malnutrition. The patient is started on continuous tube feedings which are advanced gradually, however her blood sugars remain difficult to control when eating orally in addition to the tube feedings.
This document provides a nutrition assessment and medical nutrition therapy plan for a 63-year-old male patient who underwent a laryngectomy, pharyngectomy, esophagectomy with gastric pull-up followed by radiation for squamous cell carcinoma. The registered dietitian found the patient to be at high nutritional risk due to a 23 pound unintended weight loss over the past year and being 79% of his ideal body weight at the time of surgery. The initial plan was to start enteral nutrition via tube feeding post-operatively. Follow-up notes document the patient tolerating the tube feeding well with some loose stools. The plan was adjusted to a fiber-containing formula and supplements to address this. The registered diet
This document discusses nutritional support for patients in the intensive care unit (ICU). It covers reasons for nutritional support like limiting catabolism and increasing survival. It describes assessing patients and calculating calorie and protein needs using formulas like Harris-Benedict and Ireton-Jones. Enteral nutrition is preferred over total parenteral nutrition when possible due to lower infection risks. Early enteral nutrition within 24-48 hours is associated with better outcomes. Overfeeding can cause complications so goals are tailored to patient stress level and condition.
This case study describes a 57-year-old male admitted to the hospital with nausea, vomiting, abdominal pain, jaundice, ascites, and black stools. He was diagnosed with GERD, gastrointestinal bleeding, and cirrhosis. During his hospital stay, he received various treatments including tube feeding and TPN. His condition deteriorated and he was transferred to the ICU. He later stabilized and was transitioned to an oral diet to prepare for discharge with diagnoses of chronic cirrhosis, GERD, and esophageal varices.
Medical nutrition therapy status post whipple procedureValerie Agyeman
SG, a 72-year-old female, underwent a Whipple procedure for pancreatic adenocarcinoma. She experienced significant weight loss pre-operatively and nutritional complications post-operatively including delayed gastric emptying and electrolyte abnormalities. The registered dietitian's nutrition diagnoses included malnutrition, unintentional weight loss, and altered GI function. The RD prescribed a carbohydrate-controlled diet and thickened liquids, provided nutrition education, and collaborated with other providers to optimize SG's recovery.
This document discusses nutrition in critically ill patients. It covers nutritional assessment, calculating caloric and protein requirements, and options for nutritional support including enteral and parenteral nutrition. The key points are that enteral nutrition is preferred when possible as it is more physiologic and protects gut function, and nutrition should be started early in critically ill patients to prevent catabolism and support recovery. Contraindications and complications of enteral feeding are also reviewed.
Daily minimum nutritional requirements of the critically illRalekeOkoye
The document discusses the daily minimum nutritional needs of critically ill patients. It defines key terms like critically ill patient and malnutrition. It describes the nutritional changes, assessment of nutritional state, and predictors of outcome during critical illness. It provides guidelines for calculating nutritional requirements including carbohydrates, proteins, fats, vitamins, and minerals. It discusses enteral nutrition as the preferred route of administration when possible, and provides guidelines for safe enteral feeding including early initiation and proper tube positioning.
This ppt gives you an idea of Citrulline-a naturally occuring basic amino acid, its structure, its role as marker, its uses, its clinical importance,etc.
A 57-year-old male was admitted with nausea, vomiting and abdominal pain due to cirrhosis and bleeding esophageal varices. He has a history of alcoholism. Initial labs showed hyponatremia and low albumin. A jejunostomy tube was placed for nutrition but caused intolerance. He was started on TPN with Hepatamine which was later tapered as he transitioned to an oral soft diet.
The document discusses the basis of nutritional support for critically ill patients, outlining factors that can lead to malnutrition in intensive care and the consequences of malnutrition. It covers methods for assessing nutritional status and determining nutritional requirements. Guidelines are provided on enteral and parenteral nutrition support based on a patient's condition and clinical setting.
A 57-year-old male with a history of alcoholism and cirrhosis was admitted with upper GI bleeding and black stools. Evaluation found esophageal varices and laboratory abnormalities including low sodium and albumin. He was started on medications and tube feeding but developed intolerance. A TPN was started but also not well tolerated. He was placed on a soft diet low in sodium as he prepared for discharge with a diagnosis of chronic alcoholic cirrhosis and esophageal varices.
Cystic Fibrosis Nutritional Case Study PresentationMary Rodavich
The document discusses cystic fibrosis and cystic fibrosis-related diabetes (CFRD), outlining their causes, symptoms, and treatment, including medical nutrition therapy. It also provides details of a specific 24-year-old female patient's history and condition, including her diagnosis of CFRD, and outlines her nutrition assessment, diagnosis, and prescribed nutrition interventions and monitoring.
The document discusses parenteral and enteral nutrition for critically ill patients. It recommends early enteral nutrition within 48 hours for critically ill patients without contraindications to reduce infections and mortality. For patients who cannot tolerate enteral nutrition, initiating parenteral nutrition within the first few days may be considered for malnourished patients, though the effects are unknown. The complications, formulations, administration methods, and monitoring of both enteral and parenteral nutrition are also covered.
This patient was admitted with symptoms of nausea, vomiting, abdominal pain and black stools. He has a history of hypertension, gallbladder removal and GERD. Diagnosis includes GERD, GI bleeding and cirrhosis of the liver. A jejunostomy tube was placed for nutrition due to malabsorption from liver disease. The patient was started on TPN and stabilized. TPN was tapered and the patient advanced to a clear liquid diet and then oral diet as tolerated. He was discharged on a soft diet restricted to 2000ml fluids per day with sodium and protein recommendations.
Type 2 diabetes has traditionally been viewed as a progressive disease requiring increasingly intensive treatment over time. However, recent evidence shows that type 2 diabetes is fully reversible through substantial weight loss induced by bariatric surgery or low-calorie diets. Within weeks of such interventions, fasting glucose levels can normalize as liver fat is reduced and hepatic insulin sensitivity improves. Over months, pancreatic fat depletion leads to the full restoration of beta cell function. This demonstrates that type 2 diabetes is caused by excess fat in metabolic organs and is a potentially reversible condition through weight loss and improved metabolic health.
Obesidad: nutrientes moduladores de neuropeptidos y neurotransmisoresNutriline SRL
This document discusses ketogenic enteral nutrition (KEN) as a treatment for obesity. It describes a study of over 19,000 obese patients who underwent 10-day cycles of receiving 50-65 grams of protein per day via continuous nasogastric tube infusion, without any carbohydrates. This protocol resulted in an average weight loss of 10.2 kg over 2.5 cycles, with 57% of the loss being fat mass. No significant adverse effects occurred. KEN is concluded to be a safe, fast, and inexpensive treatment that provides good long-term weight maintenance results.
This study examined how appetite, as measured by visual analog scales (VAS), is affected by weight loss through energy restriction and a low-fat diet/exercise program. Seventeen subjects participated in a 15-week weight loss program involving energy restriction followed by an 18-week low-fat diet and exercise phase. Appetite was measured using VAS before and after a standardized breakfast. Fasting cortisol, leptin, glucose and insulin were also analyzed. The study found that fasting appetite increased after both phases of weight loss. Changes in fasting cortisol best predicted changes in appetite, particularly for men. The results suggest that weight loss is accompanied by an increase in baseline appetite and that changes in fasting cortisol are the
1) The patient is a 53-year-old woman seeking pharmacotherapy for weight loss in addition to lifestyle modifications. She has a history of anxiety treated with paroxetine and past narcotic abuse.
2) Orlistat is recommended as it inhibits fat absorption and has beneficial effects on lipids, important for this patient with dyslipidemia.
3) Lorcaserin is not recommended due to potential interaction with paroxetine. Phentermine is not recommended due to risk of addiction given her history of abuse.
Similar to Acute bariatric surgery_complications__managing_parenteral_nutrition_in_the_morbidly_obese (20)
The document discusses laparoscopy procedures for various gynecological conditions such as infertility, chronic pelvic pain, ectopic pregnancy, and oncological issues. It notes that laparoscopy can be used for both diagnostic and operative purposes. It then discusses different techniques for laparoscopic access such as direct trocar insertion versus Verres needle insertion. It reviews studies comparing complication rates between different access techniques. The document emphasizes the importance of evidence-based medicine and following guidelines from organizations like NICE when determining appropriate diagnostic tests and treatments for conditions like infertility.
The document discusses laparoscopy procedures for various gynecological conditions. It begins by outlining conditions that can be diagnosed or treated via laparoscopy, including infertility, ectopic pregnancy, adhesions, endometriosis, ovarian masses, hysterectomy, uterine fibroids, and gynecological oncology issues. It then discusses different laparoscopy access techniques such as direct trocar insertion, open laparoscopy, and Verres needle insertion. It provides data on complication rates for different access methods. The document also discusses techniques for avoiding major vascular injuries during access. In summary, the document provides an overview of laparoscopy procedures and techniques for gynecological conditions.
Nuovo metodo ad ultrasuoni per il trattamento dei calcoli renaliMerqurio
This document describes a novel method using focused ultrasound to reposition kidney stones. Researchers created a kidney phantom with an artificial collecting system and lower pole. Both artificial and human kidney stones were placed in the lower pole. An ultrasound imaging probe was used to locate the stones, while a separate focused ultrasound probe could deliver bursts of ultrasound to move the stones. In experiments, stones were successfully repositioned from the lower pole to the collecting system in seconds, moving at about 1 cm/s. This noninvasive method shows promise for aiding stone clearance after surgery or during medical expulsive therapy.
Litotrissia percutanea laparoscopica nel rene pelvico casi cliniciMerqurio
This document describes a novel technique of laparoscopically assisted percutaneous pyelolithotomy for treating kidney stones in pelvic kidneys. The technique was used in 3 patients with large pelvic kidney stones who were not suitable candidates for standard percutaneous or laparoscopic approaches. The procedure involves using laparoscopy to expose the renal pelvis, then inserting a needle percutaneously into the pelvis under direct visualization. The tract is dilated and a nephroscope is used to remove stones without needing to incise or suture the pelvis. This approach provides direct access to the pelvis without risks of standard percutaneous or laparoscopic techniques. All 3 patients were successfully treated with no complications and no
Chirurgia di preservazione dell'udito. lento progresso e nuove strategieMerqurio
This study evaluated hearing outcomes for 115 patients who underwent hearing preservation surgery for acoustic neuromas. The goal was to determine the tumor size and level of pre-operative hearing that resulted in high rates of preserved hearing. Two groups of patients were evaluated based on tumor size - those with tumors ≤ 10mm and those >10mm. Patients with tumors ≤ 10mm and good pre-operative hearing (≤20dB PTA, ≥80% SDS) had a 76% success rate of preserved hearing. Patients with smaller tumors but poorer pre-operative hearing had lower success rates. The authors concluded that hearing preservation surgery is most effective for acoustic neuromas ≤10mm with good pre-operative hearing and can be an optimal treatment
Il trattamento chirurgico dei tumori del labbroMerqurio
This document summarizes a study on the surgical management of lip cancer. The study examined 32 patients treated for lip cancer over 5 years. Most cases involved squamous cell carcinoma of the lower lip. Surgical excision of the tumor was performed with oncologically appropriate margins. Reconstruction after surgery posed challenges, especially for advanced or extensive lesions. Local flaps from the lip or surrounding tissues were often used for reconstruction. Neck dissection was also performed in some cases to control lymph node metastases. While early stage tumors had good postoperative outcomes, advanced lesions resulted in greater functional impairments like drooling or chewing difficulties after surgery. The document discusses the surgical and reconstructive techniques used to treat lip cancers while aiming to preserve lip appearance and
Il trattamento chirurgico dei tumori del labbroMerqurio
The document summarizes the surgical management of lip cancer. It discusses that lip cancer is most commonly squamous cell carcinoma, usually originating in the lower lip. The management of lip cancer involves controlling the primary tumor with appropriate margins while allowing for oral competence, as well as potential neck metastases. Reconstruction is challenging, especially for advanced lesions, requiring preoperative planning and various surgical techniques. Early stage tumors have better prognostic and functional outcomes after surgery compared to advanced lesions. The authors report their experience treating lip tumors and managing neck metastases.
Effetti degli integratori di calcio sul rischio di infarto del miocardio e di...Merqurio
This meta-analysis investigated whether calcium supplements increase the risk of cardiovascular events. It analyzed 15 eligible randomized controlled trials involving over 11,000 participants who took calcium supplements for an average of 4 years. The analysis found a small increased risk of myocardial infarction among those taking calcium supplements compared to placebo, with 143 people experiencing a heart attack in the calcium group versus 111 in the placebo group. There was also a non-significant trend towards increased risks of stroke and cardiovascular death. These modest increases in risk could translate to a significant burden of disease at the population level given widespread calcium supplement use. The results suggest a reassessment of calcium supplements for osteoporosis is warranted.
Il trattamento chirurgico dei tumori del labbroMerqurio
This document summarizes a study on the surgical management of lip cancer. The most common type of lip cancer is squamous cell carcinoma, usually occurring on the lower lip. Treatment involves complete excision of the primary tumor with oncologically appropriate margins while preserving lip structure and function during reconstruction. For early-stage tumors, surgery results in good aesthetic and functional outcomes. More advanced tumors require complex reconstruction techniques using local or regional flaps to restore lip shape, texture, and mobility. Management of possible neck metastases is also important, as lymph node involvement significantly reduces survival rates. The authors report their experience treating 32 cases of lip cancer with surgical excision and various reconstructive procedures.
La sindrome rino bronchiale. indagine conoscitiva sio-aimar.Merqurio
This study aimed to standardize the diagnosis and treatment of rhino-bronchial syndrome (RBS), which links inflammation of the upper and lower airways. 159 patients meeting criteria for RBS underwent a two-level diagnostic protocol including endoscopy and spirometry. RBS was confirmed in 116 patients who had higher rates of allergic and infectious diseases than unconfirmed cases. Common symptoms were nasal obstruction, rhinorrhea, cough, and dyspnea. After 3 months of treatment including steroids, antibiotics, and nasal lavage, 96% of patients recovered. The study proposes a diagnostic workflow and highlights the importance of correct diagnosis through multidisciplinary evaluation for effective treatment of RBS.
La sindrome rino bronchiale. indagine conoscitiva sio-aimar.Merqurio
This document describes a survey conducted by the Italian Society of Otorhinolaryngology and the Interdisciplinary Scientific Association for the Study of Respiratory Diseases to better understand the epidemiology, diagnosis, and treatment of rhino-bronchial syndrome. 159 patients from 9 ENT and pulmonology centers were enrolled based on clinical history and symptoms. 116 patients received a confirmed diagnosis based on examinations of the upper and lower airways. Allergic and infectious diseases were more common in patients with a confirmed diagnosis. After 3 months of standard treatment, 96% of patients recovered. The study proposes a diagnostic workflow and emphasizes the importance of correct diagnosis through multidisciplinary evaluation and treatment.
Title: Sense of Taste
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the structure and function of taste buds.
Describe the relationship between the taste threshold and taste index of common substances.
Explain the chemical basis and signal transduction of taste perception for each type of primary taste sensation.
Recognize different abnormalities of taste perception and their causes.
Key Topics:
Significance of Taste Sensation:
Differentiation between pleasant and harmful food
Influence on behavior
Selection of food based on metabolic needs
Receptors of Taste:
Taste buds on the tongue
Influence of sense of smell, texture of food, and pain stimulation (e.g., by pepper)
Primary and Secondary Taste Sensations:
Primary taste sensations: Sweet, Sour, Salty, Bitter, Umami
Chemical basis and signal transduction mechanisms for each taste
Taste Threshold and Index:
Taste threshold values for Sweet (sucrose), Salty (NaCl), Sour (HCl), and Bitter (Quinine)
Taste index relationship: Inversely proportional to taste threshold
Taste Blindness:
Inability to taste certain substances, particularly thiourea compounds
Example: Phenylthiocarbamide
Structure and Function of Taste Buds:
Composition: Epithelial cells, Sustentacular/Supporting cells, Taste cells, Basal cells
Features: Taste pores, Taste hairs/microvilli, and Taste nerve fibers
Location of Taste Buds:
Found in papillae of the tongue (Fungiform, Circumvallate, Foliate)
Also present on the palate, tonsillar pillars, epiglottis, and proximal esophagus
Mechanism of Taste Stimulation:
Interaction of taste substances with receptors on microvilli
Signal transduction pathways for Umami, Sweet, Bitter, Sour, and Salty tastes
Taste Sensitivity and Adaptation:
Decrease in sensitivity with age
Rapid adaptation of taste sensation
Role of Saliva in Taste:
Dissolution of tastants to reach receptors
Washing away the stimulus
Taste Preferences and Aversions:
Mechanisms behind taste preference and aversion
Influence of receptors and neural pathways
Impact of Sensory Nerve Damage:
Degeneration of taste buds if the sensory nerve fiber is cut
Abnormalities of Taste Detection:
Conditions: Ageusia, Hypogeusia, Dysgeusia (parageusia)
Causes: Nerve damage, neurological disorders, infections, poor oral hygiene, adverse drug effects, deficiencies, aging, tobacco use, altered neurotransmitter levels
Neurotransmitters and Taste Threshold:
Effects of serotonin (5-HT) and norepinephrine (NE) on taste sensitivity
Supertasters:
25% of the population with heightened sensitivity to taste, especially bitterness
Increased number of fungiform papillae
ABDOMINAL TRAUMA in pediatrics part one.drhasanrajab
Abdominal trauma in pediatrics refers to injuries or damage to the abdominal organs in children. It can occur due to various causes such as falls, motor vehicle accidents, sports-related injuries, and physical abuse. Children are more vulnerable to abdominal trauma due to their unique anatomical and physiological characteristics. Signs and symptoms include abdominal pain, tenderness, distension, vomiting, and signs of shock. Diagnosis involves physical examination, imaging studies, and laboratory tests. Management depends on the severity and may involve conservative treatment or surgical intervention. Prevention is crucial in reducing the incidence of abdominal trauma in children.
Basavarajeeyam is an important text for ayurvedic physician belonging to andhra pradehs. It is a popular compendium in various parts of our country as well as in andhra pradesh. The content of the text was presented in sanskrit and telugu language (Bilingual). One of the most famous book in ayurvedic pharmaceutics and therapeutics. This book contains 25 chapters called as prakaranas. Many rasaoushadis were explained, pioneer of dhatu druti, nadi pareeksha, mutra pareeksha etc. Belongs to the period of 15-16 century. New diseases like upadamsha, phiranga rogas are explained.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of the physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar lead (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
6. Describe the flow of current around the heart during the cardiac cycle
7. Discuss the placement and polarity of the leads of electrocardiograph
8. Describe the normal electrocardiograms recorded from the limb leads and explain the physiological basis of the different records that are obtained
9. Define mean electrical vector (axis) of the heart and give the normal range
10. Define the mean QRS vector
11. Describe the axes of leads (hexagonal reference system)
12. Comprehend the vectorial analysis of the normal ECG
13. Determine the mean electrical axis of the ventricular QRS and appreciate the mean axis deviation
14. Explain the concepts of current of injury, J point, and their significance
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. Chapter 3, Cardiology Explained, https://www.ncbi.nlm.nih.gov/books/NBK2214/
7. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
Muktapishti is a traditional Ayurvedic preparation made from Shoditha Mukta (Purified Pearl), is believed to help regulate thyroid function and reduce symptoms of hyperthyroidism due to its cooling and balancing properties. Clinical evidence on its efficacy remains limited, necessitating further research to validate its therapeutic benefits.
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Rasamanikya is a excellent preparation in the field of Rasashastra, it is used in various Kushtha Roga, Shwasa, Vicharchika, Bhagandara, Vatarakta, and Phiranga Roga. In this article Preparation& Comparative analytical profile for both Formulationon i.e Rasamanikya prepared by Kushmanda swarasa & Churnodhaka Shodita Haratala. The study aims to provide insights into the comparative efficacy and analytical aspects of these formulations for enhanced therapeutic outcomes.
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
2. Table. Nutrition prescriptions, laboratory results, resting energy expenditure, and clinical status of a patient with morbid obesity after
complications after Roux-en-Y gastric bypass
PNa day 1 PN day 5 PN day 11 PN day 16 PN day 18 PN day 25 PN day 41
Weight (kg) 279 NAb NA 293 NA NA 295
kcal/day 2,050 2,050 2,050 2,050 2,050 2,050 2,050
kcal/kg actual 7.5 7.5 7.5 7.5 7.5 7.5 7.5
body weight
Protein (g/day) 155 155 105 155 155 125 125
IBWc (g/kg) 2.8 2.8 1.9 2.8 2.8 2.3 2.3
Albumin (g/dL) 1.6 1.8 1.5 1.5 1.7 2
Prealbumin (g/dL) 15 7 9
N-balanced Unsuccessful; continuous Positive 0.6 g
furosemide infusion
initiated
Indirect calorimetry 3,480
(kcal)
e f
Clinical course POD 10 initial surgery Tracheostomy Increased BUN Substantial improvement Oxygen requirement Increasing BUN Stable clinical
POD 1 wound placed and in renal function with on ventilator and status,
dehiscence, bowel creatinine decreased BUN and decreased below creatinine. granulating
resection, creatinine 60% Suspected tissues
anastomotic leak sepsis
repair, open
abdomen
a
PN parenteral nutrition.
b
NA not available.
c
IBW ideal body weight.
d
N-balance nitrogen balance.
e
POD postoperative day.
f
BUN blood urea nitrogen.
the fascia. RT returned to the surgical intensive care unit tomotic leak and compromised gastrointestinal tract
for postoperative care and remained on mechanical ven- function, as evidenced by multiple draining fistulas.
tilation.
NUTRITION INTERVENTION
NUTRITION ASSESSMENT Although guidelines are available to facilitate clinical
On postoperative day 9, PN was initiated by the physi- decisions on feeding morbidly obese individuals, actual
cian and the nutrition support service was consulted to clinical situations might not always fit within the frame-
evaluate RT for management of PN. Upon initial nutri- work provided by these guidelines. Because of RT’s class
tion assessment, it was noted that RT had been consum- III obesity, it was difficult to use traditional predictive
ing a very-low-calorie liquid diet for 2 weeks in prepara- equations to determine caloric and protein requirements.
tion for surgery (approximately 800 calories per day). In However, indirect calorimetry, the “gold standard,” was
addition, she had received only maintenance intravenous unable to be performed at this time because of her high
fluid support for 10 days since surgery secondary to her oxygen requirements through mechanical ventilation
clinical status. Based on the nutritional history collected, (fraction of inspired oxygen 60%). The nutrition support
it was determined that vitamin/mineral intake had also service decided to adjust RT’s PN prescription to provide
been suboptimal. It was evident that RT had inadequate hypocaloric feeding with additional amino acids to pro-
oral food/beverage intake (Nutrition Diagnostic Term In- mote wound healing and preservation of lean body mass
take Domain 2.1) related to preoperative liquid diet con- (Table) (4). PN was initiated on postoperative day 10 and
sumption, as evidenced by reported insufficient intake of provided 7.5 kcal/kg of actual body weight obtained before
energy (approximately 800 calories per day). On physical hospitalization, and 2.8 g/kg protein of ideal body weight.
examination, RT was found to have low muscle tone in Although RT was in acute renal failure, she started to
both upper and lower extremities secondary to her pre- produce urine and it was determined that the benefits of
surgical physical inactivity, and her family reported that meeting her increased protein needs for healing out-
she had not been able to walk for many years because of weighed the need for protein restriction for her acute
her morbid obesity and worsening arthritis. Applying renal failure at this time. RT received a tracheostomy on
Subjective Global Assessment, RT’s nutritional status postoperative day 15 because of prolonged intubation.
was categorized as normal at admission; however, she After 11 days of PN, RT’s renal function continued to
was deemed at high nutrition risk because of the com- decline and she became azotemic; her blood urea nitrogen
plexities of providing adequate nutrients, her increased increased to 105 mg/dL (37.5 mmol/L). As a result, the
postoperative energy and protein needs, and her altered amount of protein in her PN prescription was decreased
gastrointestinal anatomy (4). It was evident that RT had to 1.9 g/kg of ideal body weight.
altered gastrointestinal function (Nutrition Diagnostic On postoperative day 23, RT returned to the operating
Term Clinical Domain 1.4) related to postoperative anas- room because of increased output that appeared to be
November 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1735
3. succus from her abdominal wound. In the operating room, charge, no plans for enteral nutrition were in place be-
she was found to have multiple small bowel fistulae and cause she had evidence of multiple small bowel and co-
one colonic fistula. Because of the friable nature of the lonic fistulae. Upon discharge, it was determined that the
bowel walls at the time, repairs of the fistulae were not surgeon would continue to care for RT at the long-term
performed. Instead, small surgical drains were placed acute care facility for continuity of care; the clinician
near the fistulae for decompression and monitoring pur- communicated with the surgeon to ensure that RT would
poses. On postoperative day 26, in light of an improve- transition to enteral nutrition as soon as medically feasi-
ment in RT’s renal function, with blood urea nitrogen of ble pending closure of the multiple small bowel and co-
39 mg/dL (13.9 mmol/L) and serum creatinine down to 1.7 lonic fistulae. The clinician also communicated with the
mg/dL (150.3 mol/L), the protein content of her PN nutrition support clinician at the long-term acute care
prescription was increased back to 2.8 g/kg to facilitate facility to continue monitoring for weight loss of 1 to 2 lb
healing of her multiple intestinal fistulas. On postopera- per week with routine nitrogen balance studies to assure
tive day 28, indirect calorimetry was conducted, revealing adequate protein provision to promote wound healing.
her resting energy expenditure to be 3,480 kcal/day, with
a respiratory quotient of 0.81 and a coefficient of variance
of 10%, indicating a good measurement. Because the DISCUSSION
PN was providing only 2,050 kcal/day with 155 g protein Nutrition support in the critically ill patient can be chal-
per day, this created a 1,430 caloric deficit per day. On lenging; however, nutrition support in the critically ill
postoperative day 29, a 24-hour urine collection for urine patient who is morbidly obese is even more difficult. This
urea nitrogen was initiated; however, because of changes case report highlights the complexities in determining
in her intravenous medications, erroneous nitrogen bal- appropriate nutrition support for an individual with class
ance results were obtained, which were deemed unusable III obesity (BMI of 103 at admission) who developed mul-
for clinical application. On postoperative day 35, RT’s tiple surgical complications of the gastrointestinal tract,
blood urea nitrogen level again had been rising; therefore, with a prolonged intensive care unit stay for respiratory
the protein in her PN was decreased to 2.3 g/kg to prevent failure, sepsis, and acute renal failure. It has been shown
azotemia. Her prealbumin level had also decreased from that positive nitrogen can be achieved in the obese during
15 to 7 mg/dL (150 to 70 mg/L), which was thought to be critical illness when fed hypocalorically (13 to 21 kcal/kg
caused by a new infection secondary to her low-grade of actual body weight) with adequate provision of protein
temperatures, slowly increasing white blood cell count, (1.9 to 2.1 g/kg of ideal body weight) (5-7). Although the
and intermittent hypotension. Blood cultures and abdom- existing literature provides some level of guidance for
inal wound cultures were obtained on the same day with caloric and protein provision in the morbidly obese, there
positive infectious bacterial growth from both blood and is a paucity of research on how to optimally feed the
wound cultures. In patients undergoing hemodialysis, ni- critically ill obese. The existing literature is limited by
trogen balance can be assessed by collecting and analyz- small sample sizes and the combination of different
ing nitrogen losses through dialysate to calculate total classes of obesity (BMI range 33 to 51). Collectively, this
nitrogen appearance. However, during RT’s acute renal makes extrapolation to patient care difficult, especially in
failure, dialysis was not initiated; therefore, total nitro- individuals who have a higher BMI than those included
gen appearance could not be assessed. During the next 2 in these studies (5-7). A clinical decision was made to
weeks, RT’s clinical condition stabilized, infections were provide a lower-caloric prescription than used in the stud-
treated with antibiotics, her abdominal wound started to ies (7.5 kcal/kg) because RT’s BMI was essentially twice
develop granulating tissue, and her renal function con- that of the highest BMI included in these studies; addi-
tinued to improve. A second 24-hour urine for urine urea tional protein was also prescribed (2.8 g/kg) as a higher
nitrogen was successfully completed to assess nitrogen caloric deficit was created for RT.
balance. RT was found to be in even nitrogen balance, When providing nutrition support to the morbidly
with net balance of positive 0.6 g; it was decided at that obese individual in the intensive care unit with caloric
time that the current PN prescription was appropriate deficit and additional protein, it is often difficult to bal-
and no changes were necessary. Serum levels of trace ance the increased protein needs for the promotion of
elements were also studied as RT had been on PN for wound healing and decreased protein tolerance second-
more than 1 month with additional succus output, and all ary to acute renal failure. It is also difficult to determine
values were found to be within normal limits. Plasma the appropriate amount of caloric deficit without increas-
zinc was found to be 1,030 g/L (157.6 mol/L) (normal ing the likelihood of protein catabolism and resultant
range 600 to 1,300 g/L [91.8 to 198.9 mol/L]); whole lean body wasting. In this case report, RT did not have
blood selenium was 131 g/L (1.66 mol/L) (normal excessive gastrointestinal output causing additional pro-
range 120 to 200 g/L [1.52 to 2.54 mol/L]); whole tein losses; however, an astute clinician should always
blood manganese was 13 g/L (237 nmol/L) (normal monitor for all possible excessive body fluid losses that
range 7 to 16 g/L [127 to 291 nmol/L]). Throughout can lead to additional protein depletion. These losses
RT’s hospitalization, blood glucose was controlled with a must be accounted for in the total nitrogen balance cal-
continuous insulin infusion to maintain glucose levels at culation and the nutrition support prescription. It has
the institution’s goal glucose levels (80 to 120 mg/dL [4.44 been found by Cheatham and colleagues that a substan-
to 6.66 mmol/L]). tial amount of protein (2 g/L) can be lost through abdom-
On postoperative day 56, RT was discharged to a long- inal fluids, which further validates the need to quantify
term acute care facility for continued ventilator support, additional protein losses of body fluids (8). However, no
potential weaning, and rehabilitation. At the time of dis- other studies have been conducted to further validate
1736 November 2010 Volume 110 Number 11
4. and/or evaluate protein losses of body fluids, especially in References
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RYGB procedure, the nutrition support provided to RT nutrition support therapy in the adult critically ill patient: Society of
facilitated wound healing and eventual progression to Critical Care Medicine and American Society for Parenteral and En-
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November 2010 ● Journal of the AMERICAN DIETETIC ASSOCIATION 1737