Management of the patient with short bowel syndrome.

Extensive resection of the small bowel results in impaired digestion of macronutrients and malabsorption of nutrients, fluid, electrolytes, and minerals. Gastric acid hypersecretion and alterations in gut hormonal response further contribute to the problem. Diarrhea, dehydration, electrolyte and acid/base abnormalities, and macronutrient and micronutrient deficiencies ensue, and is termed the short bowel syndrome (SBS). Rare disorders, such as essential fatty acid deficiency and D-lactic acidosis, are a greater concern for the SBS patient. These patients' lives are significantly impacted, and they require close monitoring by a medical team knowledgeable about the disease and its nutritional, metabolic, and psychosocial consequences. Immediate therapies are directed toward fluid resuscitation, wound healing, and initiation of early nutrition support. After medical stabilization, multiple nutritional and medicinal therapies are used to aid bowel adaptation and prevent medical crisis. Advanced practice nurses should be knowledgeable about SBS to educate patients and families about this disease, associated therapies and changes in lifestyle, and how to detect and manage acute changes in medical condition.

Enteral access devices.

When the mode of nutrition support therapy is decided, it is generally accepted that the gastrointestinal (enteral) route be considered before the intravenous (parenteral) route. Currently, there are a plethora of enteral devices available and as many techniques for device insertion. This article will help the health care practitioner differentiate among the various enteral access devices available and provide care aimed at minimizing device related complications. Many complications can be prevented by keeping the devices secure, noting any migration inward or outward, and providing good site care and proper flushing. With careful selections of the type of enteral feeding device and tube tip location, most patients can be fed successfully by the enteral route.

Adult tube feeding formulas.

Adult tube feeding formulas vary considerably with respect to composition, administration, and cost. Selecting the best product for patients requires a careful analysis of specific patient requirements and resources.

The role of the gut in critical illness.

The gastrointestinal tract is a major immunologic organ that must be maximally supported during critical illness. Gastrointestinal tissues require direct contact with nutrients to support their own rapid cellular turnover rate and carry out the multitude of metabolic and immunologic functions needed for successful adaptation to stress. Disruption in the ecologic equilibrium of the gastrointestinal tract often occurs during critical illness and the therapies provided. Problems encountered include stress ulcers, intestinal ischemia, bacterial overgrowth, aspiration pneumonia, bacterial translocation, sepsis, and the systemic inflammatory response syndrome. Early enteral nutrition has been shown to be a viable, economic, and physiologically beneficial way to support the gastrointestinal tract during critical illness. The fortification of enteral formulas with glutamine, arginine, or fiber is being studied to determine each one's unique role in the gut and immunologic changes that occur with severe stress.

Comparison of weighted vs unweighted enteral feeding tubes for efficacy of transpyloric intubation.

Routine transpyloric placement of feeding tubes reduces aspiration in intensive care unit patients. Spontaneous passage eliminates the need for radiologic or endoscopic intervention. It is unclear whether the addition of a weight to the end of the tube or the use of the prokinetic agent metoclopramide in the conventional dose (10 mg) improves spontaneous transpyloric placement. In a randomized, prospective trial, 39 intensive care unit patients (age > 2 years) had a total of 50 nasoenteral tubes placed after intravenous metoclopramide (20 mg in adults, 0.2 mg/kg in children). The tubes were 8 French in diameter with either a weighted end or an unweighted bullet tip. Tip position was confirmed radiographically within 4 hours after blinded placement and at 1 and 2 days if spontaneous passage had not occurred. At 4 hours, 36% of the weighted tubes and 84% of the unweighted tubes (p < .002) had passed through the pylorus. At 1 day, 48% of the weighted tubes and 86% of the unweighted tubes (p < .007) had achieved transpyloric position. At 2 days, 56% and 92% of the weighted and unweighted tubes, respectively, had passed through the pylorus (p < .009, chi 2). The occurrence of transpyloric passage and the rapidity at which it occurred was significantly greater for the unweighted tube during all time periods. A poststudy trial was conducted to evaluate the effect of the normal dose of metoclopramide (10 mg in adults and 0.1 mg/kg in children) and the transpyloric passage of the unweighted feeding tube. Twenty-five patients received 10 mg of metoclopramide before the insertion of the unweighted tube.(ABSTRACT TRUNCATED AT 250 WORDS)

Isoelectric focusing of polypeptides from the endoplasmic reticulum and glyoxysomal membranes of castor bean endosperm.

Isoelectric focusing of the membrane polypeptides derived from castor bean (Ricinus communis L.) endosperm glyoxysomes and endoplasmic reticulum reveals a close similarity in the composition of these membranes, consistent with a developmental relationship between the organelles.