L. Beaty Pemberton

Enteral feeding in the hypoalbuminemic patient.

Previous studies have correlated intolerance of isotonic, intact protein enteral solutions with hypoalbuminemia. The purpose of this retrospective study was to determine whether the level of serum albumin (SA) influenced tolerance of such an enteral nutrient solution (ENS). All patients who received Entrition during 1987 for a minimum of 48 hr were studied for the first 10 days of enteral feeding. Documentation included SA, medications, stool frequency, gastric residuals (GR), and daily caloric intake. ENS intolerance was defined as greater than 3 stools/day for greater than 48 hr or GR greater than twice the hourly infusion rate for greater than 48 hr. Patients were categorized into two groups: those with SA greater than or equal to 2.5 g/dl (group I) and those with SA less than 2.5 g/dl (group II). Of 88 patients studied, 48 (86%) in group I and 28 (88%) in group II tolerated the ENS. Eight (14%) in group I and 4 (12%) in group II experienced ENS intolerance. There was no statistically significant difference in the frequency of ENS intolerance between these two groups (p less than 0.05). Also, 97% of all those with a SA less than 2.5 g/dl were fed 80% or more of their estimated caloric requirements. We concluded that ENS tolerance was not affected by the SA level and patients with hypoalbuminemia (SA less than 2.5 g/dl) could be fed enterally.

The significance of gallbladder trauma

This study reviewed patients with gallbladder trauma over a 14-year period treated at Truman Medical Center to determine the complications, associated injuries, and mortality rate. Fourteen patients had gallbladder trauma, 12 penetrating and two blunt. All patients underwent cholecystectomy and 10 had 3 or more associated injuries that required operative care. There were no biliary duct injuries or postoperative biliary complications. Seven patients had postoperative wound, pulmonary, or abdominal infections. There was one mortality due to delayed splenic hematoma, myocardial infarction, and cardiac dysrhythmia. Gallbladder trauma was always associated with significant multi-organ injuries that required early operative intervention.

Salmonella mediastinal abscess

Salmonella is a rare cause of a mediastinal infection. This report describes the 14-year natural history of a mediastinal mass with eventual abscess formation. Computed tomography provided excellent visualization, and surgical drainage afforded prompt diagnosis and treatment.

The Role of the Nutritional Support Team in Preventing and Identifying Complications of Parenteral and Enteral Nutrition

As the technology of parenteral and enteral nutrition advances, a multidisciplinary nutritional support team (NST) can be used to assure quality care. NST functions include developing and using standard protocols and solutions, monitoring patients, and preventing complications. Interventions by NSTs can save money for the hospital as well. Examples from Truman Medical Center (Kansas City, Missouri) illustrate how the NST can perform these functions.

Enteral Feeding During Barbiturate Coma

The extended use of pentobarbital coma in head-injured patients creates a feeding problem because of the drug-induced ileus. We evaluated the tolerance and safety of enteral feeding for head-injured patients in pentobarbital coma. Baseline nutritional assessments of the 22 patients revealed no severe nutritional deficits. Pentobarbital was initiated on admission at a rate of 128 ± 39 mg/hr for 9.9 ± 6.0 days. Enteral feedings were started at a rate of 25 ml/hr and were increased according to tolerance to a predetermined maximum rate which required 6.5 ± 4.5 days. Daily chest x-rays revealed no aspiration pneumonia. Whereas eight patients tolerated enteral feedings, seven had minor gastrointestinal complications, including diarrhea (n = 5) and constipation (n = 2). A total of 11 patients had residual volumes of 50 ml or more, but only four required alteration of the solution or route of administration. These data indicate that the majority of patients in pentobarbital coma can safely be fed enterally with ...

Special curriculum for surgery residents who fail the ABSITE

Abstract Purpose The American Board of Surgery In-Training Examination (ABSITE) documents surgical residents’ acquisition of surgical knowledge. From 1995 to 1998, after merging two general surgical residencies, 10 residents had ABSITE scores below the 30th percentile. A special curriculum was designed to address these knowledge deficiencies. The purposes of this study were to determine: (1) whether the special curriculum was effective, as measured by the next ABSITE, (2) whether the evaluation score for the special curriculum predicts the next ABSITE performance, and (3) how the special curriculum can help manage the knowledge-deficient resident. Methods Each resident filled out a questionnaire and met with the program director. The special curriculum ran from May 1 until the following March. Each resident presented a basic science conference and took the Association of Program Directors in Surgery Basic Science Course. Each resident studied a surgery textbook and took 4 examinations. Each resident was placed on probation but promoted to the next year in July. Their continuation in the residency depended on their performance in this special curriculum, clinical evaluations, and the next ABSITE. Results The questionnaire responses were: stopped studying: 10, surprised with low score: 9, no review of questions: 8, personal problems: 6, and test anxiety: 5. Basic Science conferences were above average or excellent. Conference attendance was 40%–80%. Evaluation scores were 57 to 95. The mean ABSITE percentile scores were initial = 18 (±8) and final = 48 (±35). The mean improvement was 31 (±29). The mean ABSITE standard scores were initial = 438 (±72) and final = 542 (±107) with a mean improvement of 104 (±61). Six out of 10 residents scored over 30% from 34%–97%. Four residents scored from 4%–23%. Six of the 10 residents were retained whereas 4 residents resigned. Conclusions The special curriculum provides an effective method with a due process for dealing with residents who have a deficiency of knowledge. The curriculum evaluation scores predicted the ABSITE outcome in only 70% of the residents and failed to correlate in 30%. This special curriculum separated the residents into two groups: one group passed the ABSITE with scores of 34% or above, and the other group failed, with ABSITE scores of 23% or below.