Redefining "bowel regimen": Pharmacologic strategies and nutritional considerations in the management of small bowel fistulas.

Enterocutaneous fistulae (ECF) and enteroatmospheric fistulae (EAF) are difficult complications that primarily arise after abdominal surgical procedures. Development of an ECF or EAF carries significant mortality and morbidity. Effective management of patients with these disease states requires a multidisciplinary approach, which includes surgical, pharmacotherapeutic, and nutritional interventions. This review focuses on the medical and nutritional management of ECF/EAF, providing background on drug agents and nutritional strategies that may be helpful in reducing effluent volume, optimizing fistula healing, and maintaining nutritional health.

Procalcitonin: Usefulness in Acute Care Surgery and Trauma.

BACKGROUND: Procalcitonin (PCT) is a serum biomarker currently suggested by the Surviving Sepsis Campaign to aid in determination of the appropriate duration of therapy in sepsis patients. We review the use of procalcitonin in patients after trauma or acute care surgery. METHOD: A MEDLINE search via PubMed was performed using the combination of "procalcitonin" and "humans" and "injuries, trauma," "wounds and injuries," or "wounds." Studies of burn patients, children, other biomarkers, and non-acute care surgery were excluded. RESULTS: Procalcitonin may be useful in identifying infection in trauma and post-operative acute care surgery. However, heterogenity exists among patients, and surgery and trauma alone elevate PCT even in the absence of infection. CONCLUSIONS: Although trends in PCT concentrations may offer insight, no standard approach can be recommended currently.

Use of Continuous Renal Replacement Therapy for Removal of Dabigatran in a Patient in Need of Emergent Surgery.

Purpose. To report the ability to remove serum dabigatran using continuous renal replacement therapy (CRRT) in a patient with life-threatening bleeding. Summary. A 77-year-old female with history of atrial fibrillation who takes dabigatran for stroke prevention presented with abdominal pain. Patient was found to have bleeding and possible mesenteric ischemia and was taken to the operating room and had continued bleeding postoperatively. CRRT was initiated for the removal of any remaining dabigatran, with serum dabigatran levels collected to evaluate removal of dabigatran with CRRT. This patient had an increased dabigatran level prior to intervention, which decreased to an undetectable level after use of CRRT. Greater than 80% of the drug was removed due to 4 hours of CRRT and residual kidney function. Reversal of dabigatran is an area of current research with recent FDA approval of idarucizumab for use. Conclusion. Bleeding may occur as a result of the use of dabigatran and change in patient's clinical condition. Use of CRRT may be an option in removing serum dabigatran in the case of a life-threatening bleed.

Augmented Renal Clearance in Patients with Subarachnoid Hemorrhage.

BACKGROUND: Patients with subarachnoid hemorrhage (SAH) typically exhibit hyperdynamic cardiovascular hemodynamics, which may lead to increased medication clearance. The aims of this study were to evaluate the actual creatinine clearance (CrClA) in an aneurysmal SAH population and the effect of the development of cerebral vasospasm (CV) along with its treatment to better understand if this population exhibits augmented renal clearance (ARC). METHODS: This was a prospective, single-center study in a neurosciences ICU at a university hospital. A total of 20 patients were consented and provided a 24-h urine sample to measure the CrClA. If patients experienced CV, a 24-h urine collection was repeated during vasospasm treatment. CrClA was measured using a modified Jaffe assay. RESULTS: Among the 20 patients enrolled, the mean SAH CrClA was 325.93 ± 135.20 ml/min 1.73 m(2) and this differed significantly from the SAH estimated creatinine clearance (CrClE) 144.93 ± 42.82 ml/min 1.73 m(2) (p < 0.001). Four patients developed CV; the mean CV CrClA was 558.43 ± 356.12 ml/min 1.73 m(2) and there was no significant difference when compared to those patients' mean SAH CrClA (246.91 ± 84.14 ml/min 1.73 m(2), p = 0.16). CONCLUSIONS: ARC was present in 100 % of the patients with recent SAH enrolled. Although ARC remained present in the patients who experienced CV, their creatinine clearance was not significantly further augmented. Further work is needed to clarify the impact of such clearances on renally excreted medications and how the development and treatment of CV further augment these findings.