ESPEN Guidelines on Enteral Nutrition: Adult renal failure.

Enteral nutrition (EN) by means of oral nutritional supplements (ONS) and tube feeding (TF) offers the possibility of increasing or ensuring nutrient intake in cases where normal food intake is inadequate. These guidelines are intended to give evidence-based recommendations for the use of ONS and TF in nephrology patients. They were developed by an interdisciplinary expert group in accordance with officially accepted standards and are based on all relevant publications since 1985. They were discussed and accepted in a consensus conference. Because of the nutritional impact of renal diseases, EN is widely used in nephrology practice. Patients with acute renal failure (ARF) and critical illness are characterized by a highly catabolic state and need depurative techniques inducing massive nutrient loss. EN by TF is the preferred route for nutritional support in these patients. EN by means of ONS is the preferred way of refeeding for depleted conservatively treated chronic renal failure patients and dialysis patients. Undernutrition is an independent factor of survival in dialysis patients. ONS was shown to improve nutritional status in this setting. An increase in survival has been recently reported when nutritional status was improved by ONS.

[Effect of composition of enteral nutrition on energy expenditure and CO2 production during periods of average and excessive energy intake]. / Vliv slození enterální výzivy na energetický výdej a produkci CO2 v období primereného a nadmerného prívodu energie.

UNLABELLED: The objective of the presented work is to evaluate to what extent the CO2 production and O2 utilization and energy metabolism at rest (REE) are influenced by an excessive nutrient intake and to what extent by the composition of enteral nutrition. REE, CO2 production and O2 utilization were investigated in 9 patients on complete enteral nutrition by indirect calorimetry in four modifications: I--nutrition with 40% kJ fat in a ration 1.2x the energy output at rest at the onset of the trial; II--40% kJ and high energy intake (2.4x energy output at rest; III--60% kJ fat in ration of 1.2x energy output at rest; IV--60% kJ fat and energy intake 2.4x energy output at rest. At 40% (I) and 60% (III) fat content in a caloriocally adequate diet the energy output at rest, the CO2 production and O2 utilization did not differ (mean +/- SD: 1438 +/- 264.1 kcal/24 h, 179 +/- 31.6 nl/min, 209 +/- 38.1 ml/min vs. 1431 +/- 342.7, 190 +/- 54.2, 207 +/- 46.5). Comparison of modifications II and IV revealed a significant (p < 0.05) increase of CO2 production on a diet rich in carbohydrates (218 +/- 52.0 vs. 202 +/- 42.3). The energy output at rest (1674 +/- 389.6 vs. 1661 +/- 378.7), nor O2 production (240 +/- 54.5 vs. 242 +/- 55.4) changed. Overfeeding with 40% fat (II) as compared with (I) led to a rise of the energy output at rest (p < 0.05), O2 utilization (p < 0.05) and CO2 production (p < 0.01). Overfeeding with lipids (IV) led as compared with III to a rise of the energy output at rest and O2 utilization; CO2 production did not change. CONCLUSION: The composition of enteral nutrition according to the described modification does not influences the energy output at rest, O2 utilization and CO2 production under conditions of an adequate energy intake. In case of an excessive nutrient intake nutrition with 60% fat does not lead to an increase of CO2 production.

Nutritional care of pancreatitis and its complications.

This article reviews the current literary data on the role of conservative supportive treatment for acute pancreatitis, with special emphasis on parenteral and enteral nutrition. Despite the fact that the indications for both methods have been discussed, defined and widely accepted in recent years, enteral nutrition is currently the focus of recent clinical investigations for use in acute pancreatitis.

No reduction in the sufentanil requirement of elderly patients undergoing ventilatory support in the medical intensive care unit.

The aim of the study was to test the hypothesis that the requirement of sufentanil is reduced in elderly patients when the opiate is primarily used to facilitate mechanical ventilation in a medical intensive care unit. A further aim was to study whether elderly patients developed withdrawal symptoms after discontinuing prolonged sufentanil administration. We have studied prospectively two groups of patients requiring mechanical ventilation for more than 96 h; group 1 age < 60 years (n = 316 or 68%) and group 2 age > 70 years (n = 150 or 32%). In all patients sufentanil and midazolam were administered continuously in order to facilitate ventilatory support. After an initial intravenous bolus injection of sufentanil 3.0-8.0 micrograms kg-1, the dosage was adjusted to the patients needs (0.75-1.0 microgram-1 kg-1 h) using a modified Ramsey score by accepting between 3b and 4a as the end point. The amount of sufentanil administered and side effects were recorded at 24-h intervals. Seventy-two hours following the start of sedation with sufentanil/midazolam the dose of sufentanil required for sedation increased significantly (P < 0.05) in both groups when compared with the first 24 h. There was no statistical difference between the two groups in sufentanil requirement at any time during the study. This suggests that tachyphylaxis develops to a similar degree in patients in both age groups. In addition, weaning in the elderly was characterized by a similar degree of withdrawal-like symptoms suggesting that independent of age, there are similar receptor related reactions once the opiate is withdrawn.

[Systemic amyloidosis with renal involvement]. / Povsechná amyloidóza s postizením ledvin.

Amyloidosis is a summary of a group of disorders of protein metabolism characterized by infiltration of amorphous substance into the tissues. The diagnosis can rarely be made during life. It is usually manifested by defects of the renale, cardiovascular or peripheral nervous system. Heterogenicity of clinical and histological classification of amyloidosis and clinical course in comparison with autopsy findings are presented by two cases of general amyloidosis--secondary amyloidosis of the kidneys and primary amyloidosis with a fatal prognosis.

Comparison of oxygen cost of breathing with pressure-support ventilation and biphasic intermittent positive airway pressure ventilation.

OBJECTIVE: To assess the oxygen cost of breathing with either pressure-support ventilation (PSV) or biphasic intermittent positive airway pressure ventilation (BIPAP). DESIGN: Prospective, randomized, crossover study. SETTING: Medical intensive care unit of a university hospital. PATIENTS: Twenty clinically stable and spontaneously breathing patients after long-term mechanical ventilation. INTERVENTIONS: Patients were randomized to start on either PSV or BIPAP, and measurements were performed after an adaptation period of 30 mins. Immediately after, the ventilatory mode was changed and after another 30-min adaptation period, the same measurements were performed. MEASUREMENTS AND MAIN RESULTS: Indirect calorimetry was performed during each ventilatory mode for a period of 30 mins. Oxygen consumption, energy expenditure, CO2 production, and respiratory quotient did not differ significantly between the two ventilatory modes, regardless of the patients' randomization. There were no statistically significant differences with regard to respiratory rate, minute volume, and blood gas analysis. All patients tolerated both ventilatory modes without any signs of discomfort. CONCLUSIONS: Pressure support ventilation and BIPAP are both used for weaning patients gradually from the ventilator. BIPAP may be advantageous in patients not breathing sufficiently with PSV, since no patient effort is necessary with use of this ventilatory mode.

Influence of pentoxifylline on cytokine levels and inflammatory parameters in septic shock.

OBJECTIVE: To evaluate the influence of pentoxifylline (PTX), a phosphodiesterase inhibitor, on cytokines and inflammatory proteins in patients suffering from septic shock. DESIGN: Prospective study comparing a therapy group to a matched control group. SETTING: Medical intensive care unit at a university hospital. PATIENTS: Twenty four patients fulfilling the criteria of septic shock were included in this study. Twelve patients received PTX (therapy group) and 12 patients matched for diagnosis, age and gender served as the control group. INTERVENTIONS: Pentoxifylline at 1 mg/kg per hour over 24 h in the therapy group. MEASUREMENTS AND RESULTS: Cytokine levels [tumor necrosis factor-alpha (TNF)], soluble TNF receptor [TNF-R], and interleukin-6 [IL-6] and inflammatory proteins [C-reactive protein, alpha-1-antitrypsin (AAT), fibronectin, and haptoglobin], as well as hemodynamic parameters and the APACHE III score were evaluated before initiation of therapy and 24 h-later. After 24 h, TNF levels were significantly lower in the therapy group (p = 0.013), while IL-6 levels were significantly higher in the therapy group (p = 0.030). Within the 24 h TNF declined significantly in the therapy group (p = 0.006), while IL-6 showed a significant increase (p = 0.043). AAT and the APACHE III score tended to differ significantly after 24 h between the groups [AAT levels higher in the therapy group (p = 0.05), APACHE III score lower (p = 0.05)]. In the therapy group, the systemic vascular resistance index was significantly higher after 24 h (p = 0.0026) whereas the cardiac index declined (p = 0.035). CONCLUSIONS: PTX does influence TNF levels in septic shock patients. Nevertheless, inhibiting a single mediator in severe septic shock cannot stop the inflammatory overreaction.

[A vasoactive-intestinal-polypeptide producing tumor (VIPoma) as an uncommon cause of life-threatening hypokalemia]. / Nádor z bunek produkujících vazoaktivní intestinální polypeptid (VIPom) jako vzácná prícina zivot ohrozující hypokalémie.

The authors present a case of a 40-year-old female patient examined repeatedly in the course of 11 years and hospitalized on account of pain in the hypogastrium, subfebrile temperatures, watery diarrhoea, hypokaliaemic alkalosis, weakness, fatigue and loss of body weight. As to laboratory examinations hypokaliaemia, hyponatraemia, metabolic alkalosis, irregularly elevated CRP values and minor leucocytosis predominated. A weight loss of cca 8 kg along with a severe mineral deficiency and clinical symptomatology called for parenteral nutrition with a mean daily substitution of 240 mmol K and 200 mmol Na. Due to the clinical condition and non-specific results of graphic and histological examinations the possibility of a VIPoma was considered. This diagnosis was confirmed by laboratory examinations and clinically--after the onset of corticoid treatment marked improvement of the general condition occurred. Finally the authors discuss diagnostic and in particular therapeutic possibilities in this disease.

[Temporal relationship between food intake, administration of insulin and physical loading in type I diabetics treated with an intensified insulin regimen]. / Casový vztah príjmu potravy, aplikace inzulinu a fyzické záteze u diabetiku I. typu lécených intenzifikovanými inzulinovými rezimy.

BACKGROUND: Although there is no doubt about the benefit of physical exercise in diabetic patients, risks of exercise are known in particular in type 1 diabetics. The purpose of the investigation was to assess the optimal time of exercise in relation to food intake and insulin administration in type 1 diabetics treated by intensified insulin regimens. METHODS AND RESULTS: The group comprised 31 type 1 diabetic patients without complications (21 women, 11 men) mean age 26 years, range 18-32 years with a mean duration of diabetes of 9 +/- 5.3 years and a BMI of 24.7 +/- 2.3. The patients were treated by intensified insulin regimens. In order to evaluate the blood sugar reaction they were subjected to a physical load amounting to 50% of the maximal oxygen consumption (VO2max) after exercise in the morning on fasting (state I), after administration of an insulin bolus and after breakfast (stage II) and after administration of a snack containing 20 g carbohydrate without insulin administration (stage III). The results of the blood sugar level during the 30th minute and during the fourth hour of the investigation are presented as per cent of the initial blood sugar level. Stage I ((10.1 mmol/l, SD = 5.2, 94%, SD = 54, 107%, SD = 50), stage II (9.16 mmol/l, SD = 5.1, 131%, SD = 86, 135%, SD = 97) and stage III (7.66 mmol/l, SD = 3.9, 189%, SD = 150, 153%, SD = 97). Processing of the results by Wilcoxon's test revealed a statistically significant difference of the blood sugar level after the load only between stages I and III (p < 0.01). CONCLUSIONS: In type 1 diabetics treated by intensified insulin regimens the authors did not reveal a different response of the blood sugar level to loads on fasting or after a meal and insulin. Thus it is not necessary to respect previous recommendations: to take exercise 30-60 minutes after a meal, but according to individual needs of the patients.

Emergency intubation with the Combitube in two cases of difficult airway management.

The airway was managed successfully in two cases of difficult intubation using the Combitube, a new device for emergency intubation, which combines the functions of an oesophageal obturator airway and a conventional endotracheal airway. One patient could not be intubated due to lockjaw; in the other patient, the vocal cords could not be seen because of continued vomiting. The cases illustrate the benefit of the Combitube during emergency intubation for different problems and its effectiveness as an alternative to traditional intubation techniques.

[Bronchiolitis obliterans organizing pneumonia with acute respiratory insufficiency]. / "Bronchiolitis obliterans organizing pneumonia" mit akuter respiratorischer Insuffizienz.

A 22-year-old woman was hospitalized because of fever of 39 degrees C and increasing dyspnoea. The chest radiograph demonstrated coarse confluent opacities bilaterally. Despite antibiotic treatment the condition deteriorated acutely after 2 days. All efforts to find an infectious agent, including immunological tests, were unsuccessful. Artificial ventilation became necessary because of increasing respiratory failure with an arterial oxygen partial pressure of 56 mm Hg, CO2 of 41 mm Hg and a respiratory rate of 60/min. Histological examination of a transthoracic lung biopsy revealed bronchiolitis obliterans organizing pneumonia, which was treated with prednisolone. The initial dose was 500 mg/d, gradually reduced to 12.5 mg/d over 2 weeks. The clinical and radiological findings improved markedly after 2 days and the patient discharged herself after 3 weeks and there was no follow-up.

[Comparison of the effect of continuous and intermittent physical loading in type I diabetics]. / Srovnání úcinku kontinuální a intervalové záteze u diabetiku I. typu.

In order to evaluate the optimal mode of physical loads the authors examined 19 diabetics type I without secondary complications. On the second day of an educational-rehabilitation camp the authors subjected the patients to a continuous load-a 40-minute endurance run at a heart rate equal to 60% of the maximal oxygen requirement. On the fifth day an intermittent load with a maximal intensity--training of 4 x 10 minutes with 5-minute intervals was administered. At the onset, during the 20th and 40th minute of the load the titrable acidity, lactate and blood sugar level were assessed. The intermittent load led already after 20 minutes to marked acidosis (titrable acidity = 12) which did not increase after 40 minutes of the load. The authors recorded a statistically significant rise of the lactate level (4.57 mmol/l) which after 40 minutes of the load rose further to 12.3 mmol/l, as compared with values of titrable acidity during the 20th and 40th minute (0.44 and 1.14) and lactate during the 20th and 40th minute (4.57 and 3.86 mmol/l) during a continuous load. After evaluation by the test of linear correlation it appears with regard to the stability of the blood sugar level during a load that an intermittent load is more favourable. The drop of the blood sugar level in time during a continuous load was at the 1 level of significance, in intermittent loads at the 5% of significance. Both types of loads did not lead to hypoglycaemia or other complications and thus both can be used in diabetics type I.

[Does reconditioning improve compensation in diabetics?]. / Zlepsuje rekondice kompenzaci diabetu?

The authors evaluate the short-term and long-term effect of a ten-day educational camp on metabolic compensation, the physical and mental state and knowledge of the disease in 30 diabetics type I, mean age 29 years (range 17-45 years) with a duration of diabetes of 6.3 years (plus minus 5.6). After processing of individual parameters at the onset, after termination of reconditioning and after two subsequent months the authors revealed after evaluation by the paired t-test a statistically insignificant drop of the mean blood sugar level after reconditioning. After two months the mean blood sugar level rose again insignificantly and an insignificant decline of glycosylated haemoglobin occurred. After reconditioning a statistically significant decline of insulin consumption occurred (p < 0.01) but after two months the consumption returned to the original level. A significant increase was recorded in the knowledge of the disease (p < 0.05) and an increase in physical fitness (p < 0.01). The authors consider thus that the positive effect of reconditioning is mainly in training of a proper lifestyle, learning of self-monitoring and psychic improvement.

[Successful control of hypoglycemia through education]. / Prízivé ovlivnení hypoglykemických príhod edukací.

The objective of the work was to assess whether education focused on hypoglycaemic complications can influence in a favorable way the number of these acute episodes in diabetics type I treated by an intensified insulin regime. Using a questionnaire method, the authors examined 40 diabetics type I without chronic complications, treated by an intensified insulin regime. The authors investigated the most frequent cause, clinical severity and number of hypoglycaemic episodes three months before and three months after a 10-day educational camp. During the three months before reconditioning in the group as a whole total of 600 hypoglycaemic episodes were recorded, while during the same period after reconditioning only 240. The most frequent causes before and after reconditioning were a physical load and a delayed meal. Education reduces markedly the severity and total number of hypoglycaemic episodes in diabetics type I.

[HLA tying in endogenous uveitis]. / HLA typizace u endogenních uveitid.

In a group 67 patients with endogenous uveitis without systemic disease the authors typed, using the microcytotoxic test, HLA antigens class I. The results were processed by statistical methods and compared by the chi 2 test and Fisher's exact test of probability with a control group of the healthy Plzen population. The following genes were classified as risk genes: A 30, B 5, B 27 and Cw 2.

[Hormonal changes in open-angle glaucoma. I. Levels of immunoreactive insulin in serum]. / Hormonální zmeny u glaukomu s otevreným úhlem. I. Sledování hladiny imunoreaktivního inzulínu v séru.

This paper deals with the relation of disorders of carbohydrate metabolism to etiopathogenesis of glaucoma. 102 patients with primary glaucoma of an open angle were examined and it was discovered that 80 patients from this group (78%) had an abnormal immuno-reactive insulin curve, in particular of the hypersecretory type. Standard gauge test for abnormal glucose level was administered with 31 glaucomatous patients (30%). From this point of view screening for immuno-reactive insulin is a more sensitive and reliable method than the glucose standard gauge test. It is recommended that testing for immuno-reactive insulin should be introduced for all glaucomatous patients because this can help both in the detection of early stages of diabetes and in the administration of primary prevention of atherosclerosis among the population.

[Hormonal changes in open-angle glaucoma. II. Levels of cortisol and somatotropin in serum]. / Hormonální zmeny u glaukomu s otevren m úhlem. II. Sledování hladin kortizolu a somatotropního hormonu v séru.

Observing interrelation between carbohydrate metabolism disorders and contrainsular mechanisms in a group of 102 glaucomatous patients, a higher level of cortisol in plasma was detected in 40.2% of glaucomatous patients of whom 31% had increased levels of cortisol together with IRI. In isolation the increased level of cortisol occurred in 8.9%. The frequency of increased cortisol level in glaucomatous patients is substantially lower (40.2%) than the frequency of abnormal insulin curves (78%). Increased levels of growth hormone in the group of patients occurred in 9.3% of cases and these were almost always associated with an abnormal immuno-reactive insulin curve (IRI curve). Accordingly, it is evident that hormonal disorders are a major factor in the onset of both diabetes and glaucoma.

[Retinal detachment with retinal dialysis]. / Odchlípení sítnice se sítnicovou dialýzou.

A group of 165 eyes operated on account of detachment of the retina comprised 16 eyes with oral dialysis (i.e. 9.7%). Only in 6 eyes of the group there was a positive traumatic case-history. The anatomical results of the operations were favourable (81% amotions cured), the functional results depended on the state of the macula before operation.