Post-pyloric enteral nutrition in septic patients: effects on hepato-splanchnic hemodynamics and energy status

Objective To evaluate the effects of post-pyloric enteral nutrition (EN) on hepato-splanchnic and systemic hemodynamics, metabolism and gastric mucosal energy balance in septic patients.Design Prospective clinical study.Setting Medical intensive care unit (ICU) in a university hospital.Patients Ten hemodynamically stable, mechanically ventilated patients with severe sepsis. Eight patients required norepinephrine.Intervention Low dose post-pyloric EN (Survimed, 40 ml bolus, 40 ml h^–1 continuously).Measurements and results Three data sets: F1 = baseline fasting, EN₁₂₀ = after 120 min of EN, F2=120 min after EN cessation. In addition to global hemodynamics and gastric mucosal PCO₂, we measured hepato-splanchnic blood flow (HSBF) using continuous primed indocyanine green dye infusion with hepatic venous sampling. The mean arterial pressure remained unchanged. During EN systemic vascular resistance decreased (p<0.05), while cardiac index increased (p<0.001). Simultaneously, HSBF increased during EN and decreased again at F2 (1.54 [0.88; 1.66] l min^–1 m^–2 at F1; 1.72 [1.18; 1.83] l min^–1 m^–2 at EN and 1.38 [0.91; 1.63] l min^–1 m–² at F2, p<0.001). Hepatic venous acid base status, lactate/pyruvate ratio and splanchnic lactate balance remained unchanged. There was also no change in splanchnic oxygen extraction ratio or in gastric mucosal to arterial PCO₂ difference.Conclusion The initiation of low dose post-pyloric EN in medical ICU patients with severe sepsis led to the parallel increase of systemic and hepato-splanchnic blood flow. Hepato-splanchnic energy metabolism, oxygen kinetics and gastric mucosal energy balance did not deteriorate during EN, suggesting that EN during sepsis may not be harmful even in patients requiring norepinephrine.Electronic Supplementary Material Supplementary Material is available in the online version of this article at Presented in part at 15th Annual ESICM congress, Geneva, October 2001     

Family Quality of Life: Canadian Results from an International Study

The quality of life of families that have a son or daughter with a disability has been an area overlooked by quality of life researchers until recently. The purpose of this study was to gather preliminary data on family quality of life and to report the findings of one part of an international study. The parents of 34 children and adults with intellectual disabilities were interviewed using the Family Quality of Life Survey, a measurement and assessment tool developed by a team of international researchers. Quantitative and qualitative data were collected for four concepts—opportunities available, initiative to access opportunities, attainment, and satisfaction—for each of the 9 key areas of family quality of life. In general, careers, spiritual and cultural beliefs, and family relationships were rated highly, while support from others and support from disability related services were rated quite low. Results provide a baseline for further research into the needs of these families, which is imperative for developing public policies and approaches to family-centered supports.     

Women's angiographic vitamin and estrogen trial: design and methods

The Women's Angiographic Vitamin and Estrogen trial was a randomized, double-blind, placebo-controlled study designed to test the efficacy of estrogen replacement and antioxidant vitamins for preventing angiographic progression of coronary artery disease. Postmenopausal women with one or more angiographically documented coronary stenoses of 15-75% at baseline were assigned in a 2 x 2 factorial randomization to active hormone replacement therapy (conjugated estrogens for women who had had a hysterectomy or conjugated estrogens with medroxyprogesterone for women with intact uteri) or placebo and to active vitamins E and C or their placebos. Seven clinical centers, five in the United States and two in Canada, randomized 423 women between July 1997 and July 1999. Quantitative coronary angiography was performed at baseline and repeated after projected mean follow-up of 3 years.     

Nicotine and ethanol activate protein kinase A synergistically via G(i) betagamma subunits in nucleus accumbens/ventral tegmental cocultures: the role of dopamine D(1)/D(2) and adenosine A(2A) receptors

Tobacco and alcohol are the most commonly used drugs of abuse and show the most serious comorbidity. The mesolimbic dopamine system contributes significantly to nicotine and ethanol reinforcement, but the underlying cellular signaling mechanisms are poorly understood. Nicotinic acetylcholine (nACh) receptors are highly expressed on ventral tegmental area (VTA) dopamine neurons, with relatively low expression in nucleus accumbens (NAcb) neurons. Because dopamine receptors D(1) and D(2) are highly expressed on NAcb neurons, nicotine could influence NAcb neurons indirectly by activating VTA neurons to release dopamine in the NAcb. To investigate this possibility in vitro, we established primary cultures containing neurons from VTA or NAcb separately or in cocultures. Nicotine increased cAMP response element-mediated gene expression only in cocultures; this increase was blocked by nACh or dopamine D(1) or D(2) receptor antagonists. Furthermore, subthreshold concentrations of nicotine with ethanol increased gene expression in cocultures, and this increase was blocked by nACh, D(2) or adenosine A(2A) receptor antagonists, Gbetagamma or protein kinase A (PKA) inhibitors, and adenosine deaminase. These results suggest that nicotine activated VTA neurons, causing the release of dopamine, which in turn stimulated both D(1) and D(2) receptors on NAcb neurons. In addition, subthreshold concentrations of nicotine and ethanol in combination also activated NAcb neurons through synergy between D(2) and A(2A) receptors. These data provide a novel cellular mechanism, involving Gbetagamma subunits, A(2A) receptors, and PKA, whereby combined use of tobacco and alcohol could enhance the reinforcing effect in humans as well as facilitate long-term neuroadaptations, increasing the risk for developing coaddiction.     

Frailty Could Predict Death in Older Adults after Admission at Emergency Department? A 6-month Prospective Study from a Middle-Income Country

The journal of nutrition, health & aging - The number of older adults attending emergency department (ED) is increasing all over the world. Usually, those patients are potentially more complex...     

Esophageal Doppler-guided fluid management decreases blood lactate levels in multiple-trauma patients: a randomized controlled trial

Introduction  

Esophageal Doppler was confirmed as a useful non-invasive tool for management of fluid replacement in elective surgery. The aim of this study was to assess the effect of early optimization of intravascular volume using esophageal Doppler on blood lactate levels and organ dysfunction development in comparison with standard hemodynamic management in multiple-trauma patients.