Joseph D. Ansley

Enteral hyperalimentation: an alternative to central venous hyperalimentation.

Severe protein-energy undernutrition is a frequent finding among chronically ill patients. Its causes are anorexia, hypermetabolism, and malabsorption. Adverse consequences include impaired cell-mediated immunity increased susceptibility to infection, poor wound healing, weakness, and death. Spontaneous oral intake is inadequate in patients with this disorder, and therapeutic maintenance or repletion alimentation is needed. Enteral hyperalimentation is the method of choice, if tolerated. A successful treatment program usually requires a small-bore, flexible nasoenteral tube, appropriate feeding solution, and constant flow delivery of nutrient. If only partial dietary requirements are tolerated enterally, peripheral intravenous nutrient solutions can often supply the deficit. Although not suitable for all patients, enteral hyperalimentation is more physiologic, safer, easier, and more economical than central venous hyperalimentation. It would be well tolerated by many patients who now receive nutritional repletion by the latter method.

Protein-calorie undernutrition in hospitalized cancer patients.

Abstract A survey of the nutritional status of hospitalized cancer patients was conducted in two phases. In phase 1, protein-calorie nutrition was evaluated in 54 ward patients by anthropometries, creatinine excretion and serum albumin. In phase two, 30 cancer patients with protein-calorie undernutrition were transferred to the Clinical Research Unit for study of the underlying mechanisms. Evaluation in this group included anthropometries, serum albumin, creatinine excretion, vitamin levels, caloric intake, basal metabolic rate and stool fat content. Duration of survival from study was recorded in both phases. We found a nearly universal prevalence of protein-calorie undernutrition in advanced cancer, with loss of adipose tissue, visceral protein and skeletal muscle varying unpredictably from patient to patient. The creatinine to height ratio was the most sensitive indicator of protein-calorie undernutrition; 88 per cent of the patients in both phases had a creatinine to height ratio less than 80 per cent of standard, whereas only 42 per cent and 23 per cent of these patients had values less than 80 per cent of standard for triceps skin fold and mid-arm muscle area, respectively. In phase 2, plasma folate, ascorbic acid and vitamin A levels were low in 20 to 45 per cent. Steatorrhea was rare. Neither the basal metabolic rate nor caloric intake differed from expected values for normal sedentary subjects of comparable size. The degree of malnutrition significantly correlated with survival. Patients who died within 70 days of study generally had a creatinine to height ratio We conclude that protein-calorie undernutrition is present in most hospitalized cancer patients but that it varies widely in degree between subjects and is often obscured at the bedside by residual obesity. The creatinine to height ratio, however, is a sensitive quantitative indicator of this condition. There appear to be nutritional thresholds below which survival is decreased. Survival might be enhanced if nutrition could be maintained above these critical levels.

Cardiac abnormalities in cachectic patients before and during nutritional repletion

Abstract The effect of PCU and HA on heart dimensions and function was examined with non-invasive methods in 10 patients with severe undernutrition of diverse etiology. Control subjects were 10 normal men and women matched to their cachectic counterparts by height and sex. The study was conducted in two phases. In phase A, baseline studies of heart dimensions and function were completed. Phase B consisted of cardiovascular and metabolic monitoring during 4 to 6 weeks of enteral or parenteral HA. Phase A was characterized by a reduced radiographic total heart volume, echo EdV, LV mass, and CO. These reductions, however, were only one half to one eighth as great as the losses in BW. The patients therefore entered HA with an elevated LV mass index and cardiac index. Ejection phase indices of LV function (EF and Vcf) were normal or enhanced. Phase B studies in five subjects showed that decreased cardiac size and output were correctible by HA, but at differing rates. Ventricular volume and CO corrected more rapidly than LV mass under the conditions of rapid repletion where the daily sodium intake was 2 to 4 grams, and values for cardiac index reached 250 per cent of normal. Resting metabolic rate also increased during phase B. The combination of an elevated output, excessive sodium retention, and increased metabolic rate while LV mass was still reduced appeared to be responsible for cardiac decompensation in two of five repleted patients. To prevent cardiac decompensation during the HA of undernourished subjects, we propose the use of low salt regimens, a slower rate of HA and serial monitoring of cardiac dimensions and function by clinical examination and echo.

The role of surgeon-performed ultrasound in patients with possible cardiac wounds.

OBJECTIVE The authors evaluate surgeon-performed ultrasound in determining the need for operation in patients with possible cardiac wounds. BACKGROUND DATA Ultrasound quickly is becoming part of the surgeons diagnostic armamentarium; however, its role for the patient with penetrating injury is less well-defined. Although accurate for the detection of hemopericardium, the lack of immediate availability of the cardiologist to perform the test may delay the diagnosis, adversely affecting patient outcome. To be an effective diagnostic test in trauma centers, ultrasound must be immediately available in the resuscitation area and performed and interpreted by surgeons. METHODS Surgeons performed pericardial ultrasound examinations on patients with penetrating truncal wounds but no immediate indication for operation. The subcostal view detected hemopericardium, and patients with positive examinations underwent immediate operation by the same surgeon. Vital signs, base deficit, time from examination to operation, operative findings, treatment, and outcome were recorded. RESULTS During 13 months, 247 patients had surgeon-performed ultrasound. There were 236 true-negative and 10 true-positive results, and no false-negative or false-positive results; however, the pericardial region could not be visualized in one patient. Sensitivity, specificity, and accuracy were 100%; mean examination time was 0.8 minute (246 patients). Of the ten true-positive examinations, three were hypotensive. The mean time (8 patients) from ultrasound to operation was 12.1 minutes; all survived. Operative findings (site of cardiac wounds) were: left ventricle (4), right ventricle (3), right atrium (2), right atrium/superior vena cava (1), and right atrium/inferior vena cava (1). CONCLUSIONS Surgeon-performed ultrasound is a rapid and accurate technique for diagnosing hemopericardium. Delay times from admission to operating room are minimized when the surgeon performs the ultrasound examination.

Impending aortoenteric hemorrhage: the effect of early recognition on improved outcome.

Aortoenteric hemorrhage is the result of enteric erosion and necrosis of aortic wall or anastomotic site. Mechanical or bacteriologic causes may occur singly or in combination. The temporal sequence is such that warning symptoms, often including back pain, fever, hemotochezia, and anemia, are present long before exsanguinating hemorrhage occurs. Vigorous diagnostic efforts, including gallium-67 citrate nuclear scan and computerized axial tomography, lead to a correct diagnosis. This allows planned semielective corrective operation before severe hemorrhage begins. The ideal operation consists of extra-anatomic revascularization, excision of the infected prosthesis, bowel repair with decompression, and sump drainage. Appropriate antimicrobial therapy should be continued until healing is complete. With aggressive diagnostic and therapeutic intervention according to this plan, marked improvement in survival and limb preservation can be anticipated in patients having this complication of aortic surgery. In this series, 15 of 18 patients having operation recovered, though delayed limb loss occurred in two.

Hypotyrosinemia, Hypocystinemia, and Failure to Retain Nitrogen During Total Parenteral Nutrition of Cirrhotic Patients

Six patients with gastrointestinal malabsorption and 12 with alcoholic cirrhosis received total parenteral nutrition for 4 wk. Freamine II, the source of the amino acids, is nearly devoid of cystine and tyrosine. We monitored daily nitrogen balance and other nutritional parameters and 22 plasma amino acids. Malabsorbers had a strongly positive nitrogen balance and improvements in nutritional parameters. Plasma amino acids were maintained within or above their normal fasting ranges. Eight of 12 cirrhotics resembled malabsorbing patients in terms of positive nitrogen balance, improved nutritional parameters, and plasma amino acids. In 4 cirrhotics, nitrogen balance remained negative and nutritional repletion failed to occur. Plasma cystine and tyrosine fell to below 30% of their normal fasting means. In 2 of these patients, oral supplements of cystine and tyrosine were given during the fifth week of parenteral nutrition. Plasma cystine and tyrosine were normalized, nitrogen balance became positive, and other repletion indicators demonstrated recovery. We conclude that in 4 cirrhotics, repletion was blocked by deficiencies of cystine and tyrosine, resulting from hepatic inability to synthesize cystine from methionine and tyrosine from phenylalanine.

Dacron® Interposition Shunts for Portal Hypertension An Analysis of Morbidity Correlates

Analysis of 79 Dacron® interposition shunts performed at Emory University from 1971 to 1977 identified a number of preoperative characteristics that correlate with short-term and long-term morbidity. Initial hospital mortality was related to the degree of elevation of the bilirubin and serum glutamic oxaloacetic transaminase (SGOT), to the presence of encepha-lopathy and to the urgency of the shunt procedure. Cumulative survival correlated best with the preoperative SGOT and bilirubin values, but other variables, including the Childs classification, preoperative encephalopathy, serum albumin, and the age of the patient at the time of operation, also exhibited significant associations. The hospital mortality of 13% and cumulative mortality of 48% in this series are in substantial agreement with similar reports in the literature. This experience differs widely from that described by most authors, however, in two other important respects: 1) significant hepatic encephalopathy has been observed in 45% of these hospital survivors, and 2) almost one-quarter of these patients have experienced spontaneous shunt closure. Thus, major shunt related complications have occurred in 70% of the patients to date. This incidence of undesirable consequences raises a serious question concerning the continued use of the Dacron interposition shunt for elective portal decompression.

Analysis of Twenty-three Plasma Proteins in Ascites The Depletion of Fibrinogen and Plasminogen

The concentrations of 23 plasma proteins were measured by radial immunodiffusion in the plasma and ascites of 17 patients with cirrhosis and four patients with intraperitoneal malignancies, to learn whether there is a selectivity in the movement of proteins from plasma into ascites, analogous to that of proteinuria. Additionally, since some of the proteins are involved in coagulation, we hoped to clarify the coagulopathy frequently seen following peritoneovenous shunting of ascites. Analysis was by groups: group 1 consisted of nine patients with cirrhosis with an ascites-total protein content less than 2.5 g/dl; group 2 consisted of eight patients with cirrhosis with ascites-total protein content greater than or equal to 2.5 g/dl; and group 3 consisted of four patients with malignant ascites. The ratio of the plasma concentration/ascites concentration ([P]/[A]) for each protein was calculated for each patient. In each group the median [P]/[A] for each protein was plotted against the natural logarithm of its molecular weight (In MW). For 21 of the 23 proteins, [P]/[A] showed a close linear relationship to In MW. Fibrogen and plasminogen showed significant (p < 0.0002) elevation above the regression line relating [P]/[A] to In MW. This indicates depletion of fibrinogen and plasminogen in ascites. The ascites in group 1 showed moderate selectivity, defined as the slope of the regression line (1.59), while groups 2 and 3 were essentialy nonselective (0.35 and 0.50). Fibrin-split products were elevated in all ascites but not in plasma, indicating either fibrinolysis or fibrinogenolysis within the ascites. A normal ratio for prothrombin suggests fibrinogenolysis may be the dominant mechanism. Thus the coagulopathy induced by LeVeen valve insertion may be in part secondary to the infusion of plasmin or a plasminogen activator into the circulation.

Management of liver trauma in children

The charts of 203 consecutive children undergoing emergency laparotomy for management of an acute liver injury were reviewed. Although drainage was all that was required in the majority of cases, massive hemorrhage, usually arising from disrupted hepatic veins, appeared to demand liver resection (as performed in 17 children, with a mortality of 18%) during earlier years of the survey. Control of exsanguinating bleeding from such liver wounds by packing with viable autogenous tissue (pedicled omentum) subsequently eliminated almost entirely the need for resection. Fatalities resulting from either hemorrhagic shock or loss of liver substance then became relatively rare. Additional significant problems were associated organ injuries, postoperative wound and intra-abdominal sepsis, bleeding diatheses, and late instances of hemobilia. The overall mortality was 6%.

Three Hundred Consecutive Emergent Celiotomies in General Surgery Patients: Influence of Advanced Diagnostic Imaging Techniques and Procedures on Diagnosis

ObjectivesTo assess the utility of advanced tests performed before surgery on patients who needed emergent abdominal operations, and to assess the outcomes of these patients relative to their diagnoses. Summary Background DataPatients with a potential abdominal catastrophe may have various presentations, contributing to the difficulty of the decision about whether an operation is indicated. Advanced tests can be valuable, but the use of these adjuncts should be appropriate to the clinical status of the patient so that treatment is not delayed. The role of these tools in the evaluation of the patient who may need an emergent abdominal operation is less well defined. MethodsData were reviewed on adult patients undergoing emergent abdominal operations. Entrance criteria included patients who had an emergent abdominal operation, defined as one performed for presumed gastrointestinal perforation, infarction, or hemorrhage within 6 hours of admission or surgical consultation. Advanced tests were those that were time-consuming or invasive or required scheduling with other departments so that the risk/benefit ratio of these tests could be questioned. A useful test was one that provided information that contributed to a change in the patient’s management. ResultsDuring a 5-year period, 300 consecutive adult patients (158 perforations, 66 hemorrhage, 53 ischemia/infarction, and 23 “other”) underwent emergent nontrauma celiotomies. Overall, the death rate was 20%. Advanced preoperative tests were performed in 135 (45%) of the 300 patients, and 40 of these patients had delayed treatments. Preoperative localization of bleeding sites was accomplished in 77% of patients with upper gastrointestinal bleeding and 86% of patients with lower gastrointestinal bleeding. ConclusionsMost patients in need of emergent abdominal operations should not undergo advanced tests. The primary role of advanced tests in these patients is in the localization of a bleeding site. With the exception of patients who present with hemorrhage, advanced tests frequently cause a delay in treatment.