Jejunal manometry predicts tube feeding intolerance in the postoperative period.

Postoperative nutrition is best provided enterally; however, patients often develop intolerance to enteral feedings. Our aim was to prospectively identify abdominal examination and jejunal pressure activity associated with postoperative intolerance of enteral feedings. Twenty-nine patients underwent abdominal operation and needle catheter jejunostomy placement. Elemental tube feedings were started on the day after surgery and advanced to the caloric goal rate over three days. Patients whose feedings were slowed at the attending surgeon's discretion were defined as intolerant. Jejunal manometry and a standardized abdominal exam were performed on postoperative days 1, 3, and 5. Fifteen patients (52%) were intolerant of tube feedings and had decreased jejunal motor activity but more active bowel sounds prior to feedings. After feedings, intolerant patients developed abdominal distension, but other abdominal findings were inconsistent. A marked decrease in phase II of the migrating motility complex (MMC) and the lack of a fed response were present in both groups. The overall jejunal motility present on day 1 following surgery identifies patients that will not tolerate enteral feedings. The abdominal examination, MMC parameters, and motor response to feeding did not predict feeding intolerance.

A randomized, pharmacokinetic and pharmacodynamic, cross-over study of duodenal or jejunal administration compared to nasogastric administration of omeprazole suspension in patients at risk for stress ulcers.

OBJECTIVES: The aim of this study was to characterize absorption and pH control of simplified omeprazole suspension (SOS), 2 mg/ml in 8.4% sodium bicarbonate, administered via the nasogastric versus jejunal or duodenal route. METHODS: Nine critically ill surgical patients, NPO and mechanically ventilated, were enrolled in this randomized cross-over study. Patients received a single 40 mg dose of SOS by the nasogastric and either the jejunal or duodenal route. Twenty-four-hour continuous intragastric pH monitoring was performed during the study period. Sequential blood samples were collected over 24 h to characterize SOS absorption and pharmacokinetic parameters. RESULTS: Nasogastric administration of SOS resulted in lower maximum mean +/- SD serum concentrations compared to jejunal/duodenal dosing (0.970 +/- 0.436 vs 1.833 +/- 0.416 microg/ml, p = 0.006). SOS absorption was significantly slower when administered via nasogastric tube (108.3 +/- 42.0 vs 12.1 +/- 7.9 min, p < 0.001). However, all routes of administration resulted in similar SOS area under the serum concentration-time curves (AUC(0-infinity)) (415.1 +/- 291.8 vs 396.7 +/- 388.1 microg x min/ml, p = 0.91) [corrected]. Mean intragastric pH values remained >4 at 1 h after SOS administration and remained >4 for the entire 24-h study (6.32 +/- 1.04, 5.57 +/- 1.15, nasogastric vs jejunal/duodenal, p = 0.015), regardless of administration route. CONCLUSIONS: In critically ill surgical patients, pharmacokinetic parameters and subsequent pH control after the administration of SOS are similar by the jejunal, nasogastric, or duodenal route. SOS suspension offers an alternative acid control measure when patients are unable to take oral medications, yet have an enteral tube in place.

High grade, synchronous colon cancers after renal transplantation: were immunosuppressive drugs to blame?

Recipients of renal transplants are known to have an increased incidence of cancer, which is believed to be related to the use of immunosuppressive drugs used to prevent rejection. Although the risks of lymphoma and Kaposi's sarcoma are clearly increased in this setting, the association with colon cancer is controversial. We report a 44-yr-old woman, 20 yr post-renal transplant, and with no family history of colorectal cancer or polyps, who was found to have synchronous, poorly differentiated colon cancers associated with extensive abdominal lymph node, bone marrow, and bone (skull) metastasis. The long term immunosuppressive drugs that she had received may have been an important factor in her tumor development and/or progression. Our case and literature review suggest a possible mild, increased risk of colon cancer development in patients after renal transplantation.

Clinical utility of pH paper versus pH meter in the measurement of critical gastric pH in stress ulcer prophylaxis.

OBJECTIVE: To evaluate the clinical utility of measuring gastric pH with a pH meter vs. pH paper in critical care patients. DESIGN: Prospective comparison of gastric pH measurements, using both pH meter and pH paper. SETTING: Surgical intensive care unit (ICU) at a rural Midwestern university medical center. PATIENTS: Fifty-one patients who received therapy for prophylaxis of stress ulcers in the surgical ICU. INTERVENTIONS: Therapy for stress ulcer prophylaxis was monitored. MEASUREMENTS AND MAIN RESULTS: The pH of 985 gastric samples, taken from 51 patients, was measured with both pH meter and pH paper. The pH meter and pH paper measures demonstrated a concordance correlation coefficient of .896. The mean difference between the two measures (pH paper - pH meter) was estimated to be between -0.4 and 1.4, suggesting a positive bias for the paper. The prevalence of events representing clinically relevant differences between the pH meter and pH paper in the measurement of the same gastric sample was calculated. The frequency with which each of the events occurred consecutively (or, in one case, two nearly consecutive events on the same day) was also calculated. Bias in a clinically relevant range was estimated. A set of "probability profiles" was constructed. CONCLUSIONS: A hand-held pH meter and pH paper are not interchangeable measures of gastric pH. The pH paper exhibits an appreciable positive bias compared with a hand-held pH meter in the clinically relevant range of 2 to 6. More research is needed to determine if that bias affects treatment outcomes. We recommend the use of a pH meter for patients who demonstrate pH readings of < or = 4, consecutive with readings of < or = 5.

A prospective study of omeprazole suspension to prevent clinically significant gastrointestinal bleeding from stress ulcers in mechanically ventilated trauma patients.

OBJECTIVE: To prospectively evaluate the incidence of clinically significant bleeding, side effects, and cost of therapy in mechanically ventilated trauma patients at high risk for stress ulcers who received simplified omeprazole suspension (SOS). METHODS: Prospective, evaluative study in a Level I trauma center. Mechanically ventilated trauma patients admitted with at least one additional risk factor for stress ulcer development received SOS for stress ulcer prophylaxis. RESULTS: Sixty trauma patients were enrolled. The mean Injury Severity Score was 27.3. After starting SOS, there were no cases of clinically significant upper gastrointestinal bleeding related to stress ulceration. Baseline pH was 3.3, and mean gastric pH after SOS was increased to 6.7 (p < 0.005). There were no adverse effects thought to be related to omeprazole suspension. Incidence of nosocomial pneumonia after beginning SOS was 28.3%. The cost of acquisition plus administration of SOS was $13.13 per day, whereas the cost of drug acquisition alone was $3.83 per day. CONCLUSION: In a prospective, evaluative study of 60 trauma patients who required mechanical ventilation and had at least one additional risk factor for stress ulcer development, omeprazole suspension prevented clinically significant gastrointestinal bleeding, maintained excellent control of gastric pH, produced no toxicity, and was the least costly medication alternative.

Implementation of collaborative practice through interdisciplinary rounds on a general surgery service.

Interdisciplinary teaching rounds were initiated on a general surgery service at a university teaching hospital. These rounds were designed to promote more efficient patient care by providing an opportunity for enhanced communication among health-care professionals. Improved collaboration is a prerequisite for implementation of critical paths and case management. The authors describe their methods of rounds development and the impact of the rounds on patient outcomes.

A prospective study of simplified omeprazole suspension for the prophylaxis of stress-related mucosal damage.

OBJECTIVES: To determine the efficacy, safety, and cost of simplified omeprazole suspension in mechanically ventilated critically ill patients who have at least one additional risk factor for stress-related mucosal damage. DESIGN: Prospective, open-label study. SETTING: Surgical intensive care and burn unit at a university tertiary care center. PATIENTS: Seventy-five adult, mechanically ventilated patients with at least one additional risk factor for stress-related mucosal damage. INTERVENTIONS: Patients received 20 mL of simplified omeprazole suspension (containing 40 mg of omeprazole) initially, followed by a second 20-mL dose 6 to 8 hrs later, then 10 mL (20 mg) daily. Simplified omeprazole suspension was administered through a nasogastric tube, followed by 5 to 10 mL of tap water. The nasogastric tube was clamped for 1 to 2 hrs after each administration. MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was clinically significant gastrointestinal bleeding determined by endoscopic evaluation, nasogastric aspirate examination, or heme-positive coffee ground material that did not clear with lavage, which was associated with at least a 5% decrease in hematocrit. Secondary efficacy measures were gastric pH measured 4 hrs after omeprazole was first administered, mean gastric pH after omeprazole was started, and the lowest gastric pH during omeprazole therapy. Safety-related outcomes included the occurrence rate of adverse events and pneumonia. No patient experienced clinically significant upper gastrointestinal bleeding after receiving omeprazole suspension. The 4-hr postomeprazole mean gastric pH was 7.1, the mean gastric pH after starting omeprazole was 6.8, and the mean lowest pH after starting omeprazole was 5.6. The occurrence rate of pneumonia was 12%. No patient in this high-risk population experienced an adverse event or a drug interaction that was attributable to omeprazole. CONCLUSIONS: Simplified omeprazole suspension prevented clinically significant upper gastrointestinal bleeding and maintained gastric pH of > 5.5 in mechanically ventilated critical care patients without producing toxicity.

Fluoroscopically guided nasoenteric feeding tube placement versus bedside placement.

In debilitated patients, establishment of adequate nutritional status is important to decrease morbidity and mortality. The objective of this study is to compare the relative benefits and costs of bedside placement of enteric feeding tubes to fluoroscopic placement. We did a 4-year retrospective study of 328 nasoenteric feeding tube placements. Radiology department computer and chart reviews were done to identify patients, determine the time to successful placement of the tube, and define when adequate nutritional intake was obtained through the enteric feeding tube. We evaluated relative costs, time to placement, repeat rate, and complications. Our findings show that fluoroscopic placement of nasoenteric tubes had fewer complications and allowed earlier feeding. For patients in whom immediate nutritional supplementation is needed and for whom the risk of aspiration is high, fluoroscopically placed feeding tubes are more cost effective, quicker, and more successful than blind bedside placement.

Fine-needle aspiration of breast masses.

Evaluation of breast masses is a frequent dilemma encountered by a primary care physician. Adding fine-needle aspiration biopsy to the work-up of these lesions adds an inexpensive, highly accurate test with high patient acceptance. At our institution a technique using a butterfly needle has yielded a sensitivity of 91% and a specificity of 100%.

Computed tomographic evaluation to exclude traumatic aortic disruption.

Traumatic aortic disruption from blunt trauma remains a lethal injury. The role of computed tomographic (CT) scanning in the diagnosis of traumatic aortic disruption (TAD) has been debated and varying results have been reported. We reviewed our experience with 133 consecutive cases of blunt trauma with abnormal findings on chest x-ray films of sufficient concern to require further evaluation for TAD. Of the 105 patients who underwent CT scanning as the initial evaluation, 11 (10%) required aortography (Ao) for diagnosis; seven had TAD. Twenty-eight patients with highly suggestive signs of TAD underwent Ao as the initial diagnostic test; five had TAD. Ten of the 12 patients (83%) undergoing surgical repair had good results; one died of exsanguination at surgery and the other suffered a profound neurologic injury. Follow-up by phone or chart review at 6 months to more than 5 years after injury revealed no late mortalities from unrecognized TAD. We conclude that high quality CT evaluation of patients with worrisome chest x-ray films following blunt trauma can be used to exclude TAD in the majority of cases. Aortography is reserved for cases in which there is a high clinical suspicion of TAD and for those patients in whom TAD cannot be confidently excluded by CT scanning.

Squamous cell carcinoma of the pancreas. Report of an unusual case and review of the literature.

Squamous cell carcinoma is an uncommon form of cancer of the pancreas, comprising 0.5-3.5% of cases. We report an unusual case that occurred in a very young woman and showed cystic characteristics. Interesting radiographic features included extensive pancreatic calcifications and pancreatic duct communication to the mass. A literature review of this rare form of pancreatic cancer is also provided.

Endoscopic management of retained cystic duct stones.

The finding of residual common bile duct stones after cholecystectomy is a relatively frequently encountered problem for which effective nonoperative therapy exists. Retained stones in a cystic duct remnant are very rare. We present a case of multiple retained stones in a long variant cystic duct remnant following cholecystectomy and common duct exploration, which was successfully managed with endoscopic sphincterotomy and balloon extraction.

Rewarming from experimental hypothermia: comparison of heated aerosol inhalation, peritoneal lavage, and pleural lavage.

This study compares the thermal transfer and rewarming characteristics of heated aerosol inhalation (HAI) alone and combined with peritoneal lavage (PEL) or pleural lavage (PLL). Closed-system PEL and PLL are equally efficient at rewarming hypothermic dogs and do so at a rate approximating 6 degrees C/h/m2. Cardiovascular responses to PEL and PLL were similar. Serum electrolytes, protein, Hct, and arterial blood gases were comparable and little changed when compared in prehypothermia and postrewarming periods. HAI alone provides little heat for rewarming; more heat is realized from endogenous metabolism. Nevertheless, HAI's ease of use and possible selective cardiac rewarming characteristics argue for its inclusion with other methods of active rewarming. The use of PEL or PLL is governed by clinical circumstances.

Trauma associated with three and four-wheeled all-terrain vehicles.

Death or serious injury may occur as the result of accidents involving three- and four-wheeled recreational vehicles. Thirty-two cases of such trauma requiring hospitalization at the University of Missouri Hospital were reviewed, and followup questionnaires sent to each patient. Head and extremity trauma was nine times as frequent as torso injuries. Males were injured in 81% of the cases, and the average age of all patients was 18.6 years. Fifty per cent required intensive-care monitoring and 74% required surgery. Two patients died of head injuries. Of the 25 survivors who responded to the questionnaires, 44% reported either inability to return to work or substantial interference with daily living due to their injuries. Inexperience riding the vehicle, prior use of alcohol, and lack of protective riding apparel were frequently cited as contributing factors in these injuries.

Intraabdominal pressures during natural activities in patients treated with continuous ambulatory peritoneal dialysis.

Intraabdominal pressures were measured during natural activities in 6 men, age 24-62 years, treated with continuous ambulatory peritoneal dialysis. The pressures were measured with a pressure transducer secured at the level of the umbilicus in the supine, sitting, and upright positions with 0-3 liters intraperitoneal fluid during talking, coughing, straining, changing position, walking, jogging, exercycling, jumping and weight lifting. Coughing and straining generated the highest intraabdominal pressures in every position. The pressures with weight lifting were proportional to the magnitude of the weight lifted up to 50 lbs, but were lower than those during coughing and straining. The pressures were generally higher with greater intraabdominal fluid volumes, especially with jumping and coughing. Exercycling was associated with lower intraabdominal pressure than was jogging, and the pressures were only minimally influenced by intraperitoneal fluid volumes. The results of this study can be used as a guide in establishing preventive measures in patients with intraperitoneal fluid to decrease complication rates related to raised intraabdominal pressures such as dialysate leaks, hernias and hemorrhoids.

The liver is an organ site for the release of inosine metabolized by non-glycolytic pig red cells.

The metabolic energy source used by the pig red cell, which is unable to metabolize blood-borne glucose, was examined. Potential physiological substrates include adenosine, inosine, ribose, deoxyribose, dihydroxyacetone and glyceraldehyde, of which inosine was previously implicated. A net ATP synthesis by red cells occurs during in situ perfusion through the adult miniature pig liver. HPLC analysis of the perfusate revealed the presence primarily of inosine and hypoxanthine. Inosine production by the liver was 0.015 mumol/g per min. Moreover, red cells maintain ATP when suspended in a balanced salt medium during a 6 h incubation at 38 degrees C, in which inosine is continuously infused to give an external concentration of no more than 3 mumol/l, mimicking its plasma level. Inosine consumption under these infusion conditions was 56 nmol/ml cell per h, which is two orders of magnitude lower than when inosine is present in millimolar concentration. The total red cell inosine consumption of 9.63 mumol/h is much less than the total liver inosine production of 212 mumol/h. These findings suggest that the liver is an organ site elaborating inosine, and that maintenance of a 3 mumol/l inosine in plasma is sufficient to meet the energy requirements of the pig red cells.