Central fever (CF) is defined as elevated temperature with no identifiable cause. It is basically a non –infectious source of fever in patients with traumatic brain injury.

Abstract:

Fever in patients with severe head injury is a commonly -encountered diagnostic and management problem. Neurogenic  fever (NF) or central fever  is a non-infectious source of fever in the patient with head injury and, if untreated, can cause damage to the brain in many ways. Until recently, NF was thought to be a relatively rare consequence of traumatic brain injury (TBI), but other studies have reported that four to 37 percent of TBI survivors experience this sequelae. Patients with TBI are immunocompromised to a certain extent and this predisposes them to sepsis, which should be a primary concern particularly in comatose patients. Central fever  is essentially a diagnosis of exclusion. It is only when sepsis is excluded, can we consider central fever. Though in the acute phase of severe TBI, brain temperature is indeed higher than the core temperature, but that significance is uncertain with regard to outcome prediction, since there has been a paucity of work on the use of direct methods of brain temperature monitoring. In summary, the pathophysiology and management of NF is not well understood and needs more research and understanding for better management and a favourable outcome.

Risk Factors

Many patients experience early hyperthermia (at least one episode of body temperature > 38.5°C within the first two days) after traumatic brain injury.

There is an increased risk of development of NF among patients with severe TBI who had experienced either diffuse axonal injury (DAI) or frontal lobe injury of any form. Other risk factors predicting early hyperthermia include Glasgow Coma Scale score in the emergency department < 8, paediatric trauma score < 8, cerebral oedema or diffuse axonal injury on initial head computed tomography, admission blood glucose > 150 mg/dL (8.2 mmol/L), admission white cell count> 14,300 cells/mm3, and systolic hypotension.

Pathophysiology

Cerebral temperature has been recognised  as a strong factor in ischaemic brain damage.Fever is extremely common  after acute cerebral damage, and cerebral temperature is significantly higher than body core temperature.’ Body core temperature may markedly underestimate cerebral temperature, especially during the phases when temperature has the greatest impact on the central nervous system . TBI results in many different types of injury, and at this point, it is unclear if one particular type is associated with an increased incidence of NF. NF results from a disruption in the hypothalamic set point temperature, which results in an abnormal increase in body temperature, and is thought to be caused by injury to the hypothalamus.  It may be the selective loss of warm sensitive neurons,the osmotic changes detected by the organum vasculosum laminae terminalis(OVLT) or the humoral changes modifying the firing rate of heat sensitive neurons in the medial preoptic nucleus.

Neurological Effect

The neurological effects of fever are significant as increased temperature in the post -injury period has been associated with increased local cytokine activity, increased infarct size, and poorer outcomes in the acute phase of injury. This is, in part, related to the fact that patients at risk of intracranial hypertension may be significantly affected by a rise in temperature because the intracranial blood volume increases with temperature. This reduces compliance and puts the brain at risk for further injury.Hyperthermia, from fever or other sources, when high enough (> 43°C), has been reported to cause neuronal injury in normal brains, and lengthy periods of moderate (40°C) hyperthermia have been reported to alter brain structure and functioning.Additionally, the TBI patients are at risk of secondary injury from fever because for every 1°C rise in body temperature, there is a 13% increase in the metabolic rate. This taxes the stressed energy reserves of the severely brain injured, catabolic patients. The higher metabolic demand of fever further exacerbates this problem, and can lead to additional loss of muscle and fat store.

Paroxysmal sympathetic hyperactivity is another source of hyperthermia in patients with TBI.

Clinical features/Diagnosis

It is basically a diagnosis of exclusion and needs very thorough and detailed diagnostic work up of the TBI patient. Criteria for diagnosing central fever have been suggested-

1. It typically has a rapid onset with high temperatures(more than 39 degrees) and responds poorly to antibiotics or antipyretics.
2. No prior infections or fever at least 1 week prior to the event.
3. Negative work up for fever of infectious origin or drug induced fever.

The combination of negative cultures; absence of infiltrate on chest radiographs; diagnosis of subarachnoid hemorrhage, intraventricular hemorrhage, or tumor; and onset of fever within 72 hours of admission predicted central fever with a probability of .90.

The patient with NF are relatively bradycardiac, having a notable absence of perspiration, having a plateau -like temperature curve (no diurnal variation) that persists for days to weeks, the temperature being characteristically very high, and resistant to antipyretic medications. NF may be associated with the presence of prolonged unawareness or coma state and diabetes insipidus.This often leads to expensive, invasive, and often painful tests in order to make the diagnosis.’ Differentiating a patient of NF from a patient who is having a true infectious or inflammatory source of the fever is a critical diagnostic decision for the clinicians caring for the TBI patients. The two treatment regimens differ significantly; thus rapid and proper diagnosis and treatment are essential for control of fever and optimisation of patient outcome following TBI.

Management

Rapid control of the fever is essential as it is associated with worsened outcome in both experimental and clinical studies. The treatment of NF includes use of both external cooling methods until the diagnosis is made and appropriate drug therapy. Many drugs which have successfully been used either anecdotally, or in case reports, to treat NF, include: bromocriptine,baclofen, amantadine, dantrolene, and propranolol. As each of these drugs has significant potential side effects (for example, hypotension and gastrointestinal bleeding), routine use without a relatively firm diagnosis of NF is not prudent.

References:

1. nlm.ncbi.www.nih.gov › pmc › articles › PMC4324842,case reports in neurological medicine volume 2017, article ID 1712083,BMJ,SINGAPORE MEDICAL JOURNAL 2007:48(6).

Author:

Dr. Jilmil Goswami
Fellow, Critical Care Medicine
Narayana Superspeciality Hospital, Guwahati, Assam

The post Central Fever – Is it so rare??? – a review article appeared first on CCEM Journal.

The study is to improve dialysis patient’s dietary habit for their better out come and to increase patient’s satisfaction by educating them along with their attendant about the diseases and diet management with systematic counselings.

AIM:

Increasing the patient’s satisfaction and improving the patient’s nutritional status for better outcome.

Objectives:

• Assessment of the nutritional status and feed back of dialysis patients pre and post counseling to check the patient satisfaction and physical condition.
• Collection of the biochemical parameters of dialysis patient’s pre and post counseling to check clinical condition.
• Assess the Impact of different type of diet counseling on dialysis patient’s bio chemical reports, frequency of requirement of dialysis and patient satisfaction.

Inclusion Criteria :

• All CKD PATIENTS on HD or peritoneal dialysis
• Admitted or day care patients .
• All conscious patients who were taking food orally.

Exclusion Criteria:

• Transplant patients
• Pediatric CKD patients
• Intubated or ventilated CKD patients
• CKD patients those are not taking food orally

Study Site: A Tertiary Care Centre in North East India.

An interventional study was conducted at the HD unit in three phases for a period of 3 months:

Phase 1 :

Baseline data was collected using 4 tools without any diet counseling

1. A self-administration questionnaire containing the following sections (Performa 1 ):
   • General information
   • Socio demographic data
   • Medical history
   • Dietary pattern
   • Functional capacity
   • Nutrition knowledge and attitude.
   • Biochemical Findings & Frequency of Dialysis and patient feedback to check satisfaction

2. SGA (subjective global assessment),
3. MIS (Malnutrition-Inflammation Score) to check nutritional status.
4. Dietary recall

Phase 2 :

Patients was counceled with fixed food item and Data was collected using same tools after one moth.

Phase 3 :

The patients was shifted again in second type of diet counseling which was fixed amount of food item diet counseling and the data was recollected using same tools after one month.

RESULT:

Phase 1:
No diet counseling:
Sample size – 94

Phase 2:
Fixed food items:
Sample size – 90

Phase 3 :
Fixed amount of food items:
Sample size – 82

Food Intake:

At initial phage or phase 1 food intake found to be poor in 72.34% among patients, while fair and good intake was found to be 17% and 10% respectively, where there was no counseling .

At phase2, only do and don’t were provided , after that which shows poor intake category decreased to 42.22 % and fair and good intake categories were increased to 20% and 32.22% . 5% percent of patients also found to have excellent food intake in phase 2.

At phase 3 , poor intake category dropped to 34.15% where as  fair , good and excellent food intake categories increased to 24.39%, 32.92% and 8.54% respectively.

Impact Of Food Consumption:

Impact of food consumption in phage 2 and phage 3 is quite visible as in phase 1 improved rate was 84.5% and phage 3 , improved rate was 93.90%.

Similarly , a study done on adolescence showed nutrition counseling was effective to change their food consumption behavior as they were switched to healthy meals instead of junks(Singla, Sachdeva & Kochhar,2012).

Consumption Of Food Items:

During phage I 100% of patients were sacred to eat most of things in their plates, while in phage 2 improvement was found very little because of dis-likeness of allowed items while phage 3 was showed great improvement in their food choice in plate which was 85.36%. which clearly shoes that only by restricting food items we can not see significance improvement.

Study reported , Nutrition counseling sessions in previously malnourished renal dialysis patient showed great improvement in nutritional knowledge and practices that led to improved health status and also their performance in daily activity of life(Hegazy, et.al, 2013)

Conclusion:

Counseling could be the best way to improve patients food habit and choices. An Effective counseling with broad food item choice with proper portion size helps to improve not only their food intake but also mind satisfaction. Present study showed great improvement in dialysis patient in terms of food intake , food consumption from phase 1  till phase 3 where phase 1 had no counseling , phage 2 was involved only dos and don’ts 90 (fix item) counseling and lastly phase 3 which comprises of providing portioning size from different food groups with frequencies hence allowed large food choices rather than constricting themselves to only some food items.

References:

1. Lynch KE, Lynch R, Curhan GC, Brunelli SM. Prescribed dietary phosphate restriction and survival among hemodialysis patients. Clinical journal of the American Society of Nephrology : CJASN. 2011;6:620–629. [PMC free article] [PubMed] [Google Scholar]
2. Ewers B, Riserus U, Marckmann P. Effects of unsaturated fat dietary supplements on blood lipids, and on markers of malnutrition and inflammation in hemodialysis patients. Journal of renal nutrition : the official journal of the Council on Renal Nutrition of the National Kidney Foundation. 2009;19:401–411. [PubMed] [Google Scholar]
3. Vijaya K.L, Mesa Aruna , Rao narayana S.V.L  and Mohan R.P. Dietary Counseling by Renal Dietician Improves the Nutritional Status of Hemodialysis Patients:Indian Journal of Nephrology(2019)
4. kochhar Anita, Sachdeva Rajbir and Singla priya .Impact of Nutrition Counseling on Consumption Pattern of Junk Foods and Knowledge, Attitudes and Practices among Adolescent Girls of Working Mothers:Journal of Human Ecology(2012)
5. Abdel Aziz.S.B ,Elhabashi.E.M, Hegazy I.S and Raghy HA.EI. Study of the effect of dietary counselling on the improvement of end-stage renal disease patients: Eastern Mediterranean Health Journal(2013)

Author:

Ms. Shabista Nasreen
Chief Dietician, Narayana Superspeciality Hospital, Amingaon, Assam

Mr. Dipjyoti Das
Dietician, Narayana Superspeciality Hospital, Amingaon, Assam.

The post Impact of Systematic Diet Counseling on CKD Stage V Patients appeared first on CCEM Journal.

As technology is significantly advancing in healthcare, people live longer while burdening with non communicable diseases. The parallel increase in life expectancy and co morbidities has a direct impact in the healthcare economy while adding new challenges to the health care professionals. In 21^st century, transformative healthcare approaches, patients are considered consumers who expect much more higher from healthcare compared to before.

Health care professional plays a pivotal role in enhancing patient education to take care of themselves. Studies have shown that there is co-relation between imparting education to patient and family with improving patient satisfaction. The need for health care professionals to educate patient and family is highlighted as a “rights” and become a standard by accreditation bodies like NABH, JCIA, etc…which meant to “enhance the patient’s knowledge, skills, and behaviors necessary to fully benefit from the health-care interventions provided by the health care organization.”

Patient education and satisfaction are known to be very important measures in the current healthcare environment that will have a financial impact on healthcare. In the past, healthcare facilities had no way of directly measuring the satisfaction level of patients in the form of service delivery.

Patient always prefer health care organization who respects patient’s time and inform everything to the patient in timely manner. E.g. if a patient is made aware of the time frame of a test or procedure may take, he/she is more likely to wait patiently. If the time frame has to be extended, information to the patient will make him or her more tolerant of delays

Deming Cycle for Quality Improvement:

Plan

1. To systematically review the VOCs for identifying the problems related to patient satisfaction.
2. Find different strategies for improving patient satisfaction.

Methodology:

Setting:  Apollo Hospitals, Guwahati.

Period:  June to November 2019.

Sampling Technique:  Convenient sampling.

Data Collection Tool:

Data were collected from:

• Patient feedback online portal (Voice of Customer)
• Daily chairman round report.

Result (Pre-intervention):

During analysis following issues were identified:

• Patient and family members were not satisfied with overall care as the treatment plan, procedures; ongoing medications were not explained well to them.
• Patient and family education was not provided in regular basis as required.
• Language barrier were found between patient and nursing staff as many nurses do not speak local language.
• Time constraint of nurses was found as they are busy for many clinical activities.

Analysis of Data (pre-intervention):

Fig-2:  Number of complaints for nursing department (VOC)

Fig-3:  shows the number of compliments for nursing department -VOC

Fig-4:  shows the number of complaints during chairperson for nursing department

Do/ Perform:

The following steps were introduced to enhance knowledge and understanding of the patient and their family members.

• Leaflets for educating patient and families were prepared to impart more knowledge on few important subjects (e.g. safe medication practices for pediatric, vaccination etc.).
• Nurses emphasized lots on providing patient and family education in simplified manner in their level of understanding of the subjects.
• Checklist was prepared for nurses to educate patient as “What to Orient to the Patient” in beginning of each shift.

Pediatric Patient Family Education Pamphlet

Pamphlet for Adult Patient & Family Education

Act

• Trainings were conducted in both the classroom as well as in the clinical areas.
• SOP on Patient Family Education (PFE) was learned by each staff in the month of Oct, 2019 as a corporate project.
• PFE were performed in different units to improve patient satisfaction.

Check/Monitor

• Data were again analyzed after the intervention.
• All the above mentioned interventions were carried out and VOCs were assessed.
• Chairman rounds report were monitored continuously.

Fig-5:  shows the number of complaints for nursing department -VOC

Fig-6:  shows the number of complements for nursing department -VOC

Fig-7:  Shows the number of complaints for nursing department during chairman round

Act/Improve

• Continuous emphasis on daily education to the patient and family.
• Periodic reinforcement training to all nurses on the subject.
• Periodic audit by NS & other senior nursing leaders about patient orientation by staff as per the checklist.
• Instant reporting of any incidence of dissatisfaction/ complaint.

Recommendation:

• Since, PFE is important activity to enhance the satisfaction level of the customer, a dedicated nursing team can be formed who can perform this activity in regular basis.
• A dedicated nurse can work as a ‘Care Companion’ nurse who can assist patients from admission to discharge including follow-up after discharge as per requirement.

Author:

Ms Pinaki Bayan
Nursing Superintendant, Apollo Hospital Guwahati.

Ms Oinam Bidyalaxmi
Nursing Quality Officer, Apollo Hospital Guwahati.

Ms Karishma Khaund,
Nursing Learning Officer, Apollo Hospital Guwahati.

The post A study to assess the impact of PFE (Patient Family Education) on Patient Satisfaction appeared first on CCEM Journal.

• To ensure that nutritional requirements of critically ill patients shall be met with ideal calorie and protein density or modifications necessary in particular nutrient composition.
• Critically ill patients who are not able to take oral feed shall be nutritionally supported by giving enteral feed.
• Only commercially available nutritive formulae are used.
• Once the patient has been fluid resuscitated and stabilized on declining doses of <2 vasopressors, EN may be started cautiously at low rates.
• In persistent shock, early EN should be avoided (A I).
• If patient hemodynamically stable then feed start within 24 hours.
• 80% calorie and other nutrients target should be achieved within 24 – 48
• Tube feeding to be considered if even 50%–60% of nutrition targets are not met adequately within 72 h of oral nutrition support.
• In case the nutrition requirement is not met adequately with EN even after 7 days of ICU admission, then usage of parenteral nutrition may be considered.

Procedure:

• Enteral Tube nutrition
• Authorization: dietician and doctor
• New Admission
  • Treating consultants based on the clinical and patho-physiological parameters of the patient shall assess and give written order to start enteral feed.
  • Instructions (volume and nutritional requirements) in the patient’s medical record. The ward secretary/ sister in charge shall inform the dietician through the Special Diet Requisition Slip or through phone.
• Process of RT feed
  • Doctor written order
  • Nurses inform to dietician
  • Dietician consult with doctors and calculate calories and decide the method (continuous or bolus) and writes in feed chart and assessment form
  • Nursing staff follow the instruction till further advice
  • Any change in the advice by doctor
  • Nursing inform to dietician/dietician get information through taking rounds
  • Dietician writes in the assessment form about the change
  • Nursing staff follow the instruction till the next advice by doctors

Diet Change:

• The treating consultant shall communicate through written instructions for each patient in the medical record for any enteral feed modification (changes in volume and/or nutritional requirements and method of feed).

Periodicity:

• Based on the clinical condition of the patient the consultant shall give instructions for changes in the enteral feed plan, which may vary from 1-3 modifications in a 24 hour diet cycle. The same information shall be communicated to the Dietician by the nursing in-charge/allocated sister.

Documentation:

• Progress Note: The specific enteral feed instructions for each patient shall be prescribed by the treating consultant in the patient’s medical record in the progress note.
• Special Diet Requisition Slip: Allocated nurse should write the special diet order mention in progress note and sent it canteen and also provide information to dietician.
• Dietician will write the instruction about RT feed in nutritional assessment form. And she need to update every time after any changes in RT feed and will document in reassessment form.

Nutritional Assessment:

• Authorization :dietician
• New Admission: Concerned floor dietician after receiving the enteral feed instructions in the form of Special Diet Requisition Slip shall carry out the nutritional screening and assessment within 24 hrs of admission on a Nutritional Assessment and Planning Format.
• Diet Change: The concerned floor dietician in accordance with the enteral feed prescription given by the treating consultant shall formulate the feed.
• Modification: The concerned floor dietitian shall do modifications in the current enteral feed formula.
• Periodicity: As and when the message is received.

Documentation:

• New Admission: Nutritional screening shall be filled in Nursing Assessment on admission Form (done soon after admission by the sister in charge), Nutritional screening and assessment shall be filled in Nutritional Assessment and Planning Form (done within 24hours of admission by the allocated floor dietician).
• Diet Change: Initiation of Special Diet Requisition slip/ OR Telephonic
• Modification: Putting up and Reviewing of Nutrition Chart.

Translating prescription into Enteral feed formula:

Authorization: Dietician shall be authorized to plan the enteral feed formula in consultation with the treating consultant.

• Calculation: The calorie and protein requirements shall be scientifically calculated based on the BMI and physical activity of the patient or RDA (as given by ICMR for under 18) or BEE (as per Harris Benedict’s Equation)
• Formulation for adults:

1. CALORIES
   • should be in range of 25-30 Kcal/kg body weight/day for most critically ill patients(A I)
   • A whole‑protein formula providing 35–40 kcal/kg body weight/day energy intake is recommended in  Hepatic  Failure patients(A I)
   • Harris-Benedict prediction equation x injury factor
     • Male : BEE = 66.47 + (13.75 x weight in kg) + (5.0 x height in cm) – (6.76 x age in years)
     • Female : BEE = 655.1 + (9.56 x weight in kg) + (1.85 x height in cm) – (4.68 x age in years)

1. PROTEIN
   • Protein requirement for most critically ill patients is in range of 2-2.0 g/kg body weight/day(A I)
   • In severely hypercatabolic patients such as extensive burns and polytrauma, ratio of Kcal: nitrogen should be 120:1 or even 100:1 has been accepted (B V)
   • A whole‑protein formula providing 2–1.5 g/kg body weight/day protein is recommended  in  Hepatic  Failure patients(A I)
   • Protein recommendations should be in the range of 5–2.5 g/kg/dayTraumatic Brain Injury (A I)
   • Daily protein intake should be in the range of 1.2–1.7 g/kg actual body weight in AKI patients (C)
   • Standard enteral formula is recommended for ICU patients with AKI (A I)In case of significant electrolyte imbalance, a specialty formulation designed for renal failure should be considered (A I)
   • As percent of total kcal: 15 – 25%
2. LIQUID
   • By weight: 25 – 35 ml/kg depending on age, sex, activity
   • By calorie intake: 1 ml/kcal
   • Limit in CHF, edema, oliguria, hyponatremia, SIADH
   • Increase if abnormal gastrointestinal, skin or renal fluid losses
   • Consider all sources, intravenous, enteral and oral
3. TIMINGS:
   • 2nd / 3rd hourly
4. SUPPLEMENTS:
   • Only formula feed
   • Enteral nutrition should not be interrupted in the event of diarrhea (A I) Feeds can be continued while evaluating the etiology of diarrhea (A I)

• Formulation for Pediatrics :

1. CALORIES

• Pre operative or post shunt
  • 90-100kcal /kg( ventilated)
  • 120-150kcal/kg(non ventilated)
• Post operative or post shunt
  • 90-100kcal /kg( ventilated)
  • Actual body weight + activity 1.2+ stress1.5-1.6 (non ventilated)

1. PROTEIN

• Follow RDA.

1. LIQUID
   • 150ml/kg (Premature < 2kgs )
   • Neonates and infants 2-10kgs(0-6months) is 150ml/kg  and  for  6-12 month is 120ml/kg
   • Infant and children 10-20kg is 1000ml +50ml over 10kgs
   • Children >20kg is 1500ml +20ml over 20kgs
   • Consider all sources, intravenous, enteral and oral
2. TIMINGS:
   • 2^nd/ 3^rd hourly/ Continuous 75ml /hourly
3. SUPPLEMENTS:
   • only formula feed
   • Enteral nutrition should not be interrupted in the event of diarrhea (A I) Feeds can be continued while evaluating the etiology of diarrhea (A I)

• Documentation: Enteral feed formula shall be planned on Nutrition Chart Formulation form and it shall be documented in Nutrition Chart. Subsequent planning for next day shall be done on Nutritional Re-assessment & Planning form and if completely the feeds / nutritive values are to be altered a new Nutrition Chart will be put up by the concerned floor dietician.

Therapy Plan

• Authorization: Only dietician is authorized to fill the therapy plan and response to nutrition is recorded.
• Periodicity: Frequency of updating shall be every day or as per nutritional requirement.
• Documentation: All the updations or modifications are recorded in Nutritional Re-assessment & Planning form by the Dietician.
• Parenteral nutrition: Treating consultant shall prescribe parenteral nutrition formulae and the volume of administration in consultation with the dietician..
• Preparation, storage handling and distribution of parenteral feeds shall be the responsibility of the pharmacy. Administration of Parenteral nutrition shall be done by nursing staff. Dietician shall record the calorie and protein intake for 24 hours on Nutritional Re-assessment & Planning form.

RT feed protocol:

• Start feed for patient with contentious feeding by giving plain polymeric formula with RTH. Target 1000 Kcal in first 24 hours. Try to archive required nutrients target with in 72 hours for patients by bolus or contentions or both type of feeding.
• Combination of intermittent continuous and bolus feed is best way to provide required nutrition with less nursing timing. So RTH can be given in day time when nursing work load is very high mainly 11am to 4 pm in combination 4 to 5 bolus feedings.
• In case of bolus feeding initiation RT feed should be start with 50ml and followed by 100ml then 150ml and finally 200ml 2nd hourly which is a full strength of a feed according to the patient condition and tolerance.
• If patient is not tolerating more than 100ml then only 100ml feed will be continued as per doctor advice.
• Each time feed is given, tube should be flushed with 30ml of clear water.
• Residual volume should be checked four hourly and if it is above 300ml then it should be informed to doctors.
• In case patient is missing feed due to some test and other reason RTH should be given in night time as continuous feed.
• In case of loose stool, diarrhoea and uncontrolled sugar continuous feed should be given.
• Try to start feed within first 12 hours if there is no contra indication.
• Prefer continuous feeding.
• Start feed with the rate on 10- 20 ml hourly and slowly increase to 60 to 75ml hourly.
• Try to achieve 80% of required nutrition.
• If kept NPO for any procedure/test cover the feeding gap by giving continuous feed in night time too.
• Prepare feed only for 4 to 5 hours.

Author:

Ms. Shabista Nasreen
Chief Dietician, Narayana Superspeciality Hospital, Amingaon, Assam

The post Nutritional Process In Patients On Enteral Or / And Parenteral Nutrition appeared first on CCEM Journal.

Isolated lateral STEMI is less common, but may be produced by occlusion of smaller branch arteries that supply the lateral wall, e.g. the first diagonal branch (D1) of the LAD, the obtuse marginal branch (OM) of the LCx, or the ramus intermedius.

Recognition of a lateral STEMI:

• ST elevation in the lateral leads (I, aVL, V5-6).
• Reciprocal ST depression in the inferior leads (III and aVF).
• ST elevation primarily localised to leads I and aVL is referred to as a high lateral STEMI.

CASE REPORT:

A 46yr old male patient with primary complaints of Fever since last 4 days for which he took self medication from a local pharmacy. After 3 days at around10am patient developed heaviness of chest with mild pain which was radiating to back, patient went to the same pharmacy and took inj.pantoprazole(i.v) after which symptoms apparently subsided. The next morning patient again developed similar symptoms and was taken to a local hospital where after doing ECG he was diagnosed to have ACS-STEMI. Patient condition deteoriated in the hospital and CPR was given(according to patient party) after ?Asystole. ROSC was achieved and the patient was immediately reffered to NH for further management.

Upon arrival in ER patient was still complaining of severe left sided chest pain. ECG showed Lateral Wall MI(ST elevation in the lateral leads – I, aVL, V5-6) and the patient was in Shock (? Cardiogenic / Vasopressors started immediately). Blood sample was taken for Trop-I and Cardiologist was informed immediately. Bed side 2D-Echo was done which showed Cardiac Tamponade and Transmural involvement was suspected. CTVS opinion was taken later and poor prognosis was explained to the patient party. In the mean time Trop-I report showed 8.56ng/ml.

Discussion:

All patients suspected of having LMI should have a thorough history and physical exam performed. Details regarding the nature of chest pain including onset, aggravating/relieving factors and radiation can help make an important clinical decision. Patients should be examined for signs of excessive lipid accumulation such as xanthoma and xanthelasma. Physical findings such as diaphoresis, extra heart sounds, heart murmurs, and elevated jugular venous pressure can guide toward the diagnosis of LMI.[1] Patients suspected of having acute LMI should have a prompt evaluation with an electrocardiogram (ECG) and measurements of serial cardiac troponins.[2] Recognizing distinct ST-T involvement pattern can aid in early diagnosis of MI.

ECG Findings:

• ST-Elevated LMI: ST elevation in lead I, aVL, V5, and V6; Reciprocal ST depression in inferior lead III and aVF
• High lateral STEMI: High lateral STEMI can present as ST elevation involving lead I and aVL. Subtle ST elevation in V5, V6 and reciprocal changes in lead III and avF may be present. This is usually caused by occlusion of the first diagonal branch of LAD and is sometimes referred to as South African flag sign.
• Old LMI presents with deep and broad Q waves I leads I and aVL
• Inferolateral STEMI presents with ST-elevation involving lateral (I, aVL, V5, V6) and inferior leads (II, III, aVF):This is usually seen with occlusion of the proximal LCx artery.
• Anterolateral STEMI presents with ST-elevation involving lateral (I, aVL, V5, V6) and anterior leads (V1, V2, V3):This is highly indicative of proximal LAD occlusion.

In patients with normal troponin and non-diagnostic ECG, a quick evaluation with echocardiogram can be done. Echocardiogram has high sensitivity and low specificity when diagnosing MI. [3]Severe ischemia produces regional wall motion abnormalities (RWMA) which can be visualized on echocardiogram. However, it is difficult to differentiate acute ischemia from old infarct based on RWMA. Patients with normal echocardiogram but having moderate pre-test probability should be evaluated with a stress test.[4]

LMI presenting as STEMI should be treated immediately. Early reperfusion has shown benefits with improved clinical outcomes.[5] Percutaneous intervention (PCI) has demonstrated superior results when compared to fibrinolytic therapy.[6] ACC/AHA guidelines for STEMI management recommend early PCI with preferable door to balloon time of fewer than 90 minutes at PCI capable facility and less than 120 minutes at non-PCI capable facility.[7] Antiplatelet therapy with aspirin and either P2Y12 inhibitor or Glycoprotein IIb/IIIa inhibitor is recommended before and after PCI. Multiple studies have demonstrated mortality benefits with beta-blockers and high-intensity high potency statins.[8]

LMI patients presenting as NSTEMI should receive initial medical therapy with oxygen (if hypoxic), beta-blocker, and a statin. Antithrombotic therapy including antiplatelet medications and anticoagulants such as unfractionated heparin should be initiated as soon as possible. NSTEMI patients have also shown better outcomes with early reperfusion strategy.[9]

LMI has overall favorable outcomes. Long-term outcomes in patients with STEMI and NSTEMI have improved over the last decade.[10]

Prognosis tends to be worse in patients presenting with life-threatening complications such as arrhythmias, sudden cardiac arrest, free wall/papillary muscle rupture and cardiogenic shock. Risk stratification using TIMI scores can help identify patients with increased in-hospital mortality.[11]

Conclusion:

Widespread misinformation and ignorance of common men about Chest Pain/Heaviness which sometimes have similar symptoms as Gastritis have led to worst outcome for many. As medical intervension/attension usually gets delayed in such cases resulting in poor prognosis and sometimes even death.

Our patient was having chest pain/heaviness almost 24-hour before seeking medical help, he was taking PPI`s thinking he is having gastritis. By the time he came to see a doctor in his locality it was already very late and the time taken by him to reach our hospital after referral led to more damage.

It can finally be concluded that,“In any kind of Chest Dyscomfort medical attention should be taken immediately.“

Reference

1. Esmat S, Abdel-Halim MR, Fawzy MM, Nassef S, Esmat S, Ramzy T, El Fouly ES. Are normolipidaemic patients with xanthelasma prone to atherosclerosis?  Exp. Dermatol. 2015 Jun;40(4):373-8. [PubMed]
2. Sabia P, Afrookteh A, Touchstone DA, Keller MW, Esquivel L, Kaul S. Value of regional wall motion abnormality in the emergency room diagnosis of acute myocardial infarction. A prospective study using two-dimensional echocardiography. 1991 Sep;84(3 Suppl):I85-92. [PubMed]
3. Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB, Kligfield PD, Krumholz HM, Kwong RY, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR, Smith SC, Spertus JA, Williams SV., American College of Cardiology Foundation. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS guideline for the diagnosis and management of patients with stable ischemic heart disease: executive summary: a report of the American College of Cardiology Foundation/American Heart Association task force on practice guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. 2012 Dec 18;126(25):3097-137. [PubMed]
4. Bose A, Jain V, Kawthekar G, Chhabra C, Hemvani N, Chitnis DS. The Importance of Serial Time Point Quantitative Assessment of Cardiac Troponin I in the Diagnosis of Acute Myocardial Damage. Indian J Crit Care Med. 2018 Sep;22(9):629-631. [PMC free article] [PubMed]
5. Anderson JL, Karagounis LA, Califf RM. Metaanalysis of five reported studies on the relation of early coronary patency grades with mortality and outcomes after acute myocardial infarction.  J. Cardiol. 1996 Jul 01;78(1):1-8. [PubMed]
6. Keeley EC, Boura JA, Grines CL. Primary angioplasty versus intravenous thrombolytic therapy for acute myocardial infarction: a quantitative review of 23 randomised trials. 2003 Jan 04;361(9351):13-20.[PubMed]
7. O’Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso CL, Tracy CM, Woo YJ, Zhao DX, Anderson JL, Jacobs AK, Halperin JL, Albert NM, Brindis RG, Creager MA, DeMets D, Guyton RA, Hochman JS, Kovacs RJ, Kushner FG, Ohman EM, Stevenson WG, Yancy CW., American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 Jan 29;127(4):e362-425. [PubMed
   
8. O’Gara PT, Kushner FG, Ascheim DD, Casey DE, Chung MK, de Lemos JA, Ettinger SM, Fang JC, Fesmire FM, Franklin BA, Granger CB, Krumholz HM, Linderbaum JA, Morrow DA, Newby LK, Ornato JP, Ou N, Radford MJ, Tamis-Holland JE, Tommaso JE, Tracy CM, Woo YJ, Zhao DX., CF/AHA Task Force. 2013 ACCF/AHA guideline for the management of ST-elevation myocardial infarction: executive summary: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines. 2013 Jan 29;127(4):529-55. [PubMed]
9. Shetabi K, Ullah R, Patel R, Wilson T, Siddiqua T, Olet S, Ammar KA, Jahangir A, Allaqaband SQ, Bajwa T, Jan MF. Contemporary practice pattern of revascularization in a large tertiary care referral center in non-ST elevation myocardial infarction: A propensity-matched 10-year experience. Catheter Cardiovasc Interv. 2019 Feb 01;93(2):256-263. [PubMed]
10. McManus DD, Gore J, Yarzebski J, Spencer F, Lessard D, Goldberg RJ. Recent trends in the incidence, treatment, and outcomes of patients with STEMI and NSTEMI.  J. Med. 2011 Jan;124(1):40-7. [PMC free article] [PubMed]
11. Morrow DA, Antman EM, Parsons L, de Lemos JA, Cannon CP, Giugliano RP, McCabe CH, Barron HV, Braunwald E. Application of the TIMI risk score for ST-elevation MI in the National Registry of Myocardial Infarction 3. 2001 Sep 19;286(11):1356-9. [PubMed]

Author:

Dr.Nobibul Rahman
Fellow, MEM, Narayana Superspeciality Hospital, Guwahati, Assam

The post ACS-STEMI (Isolated lateral wall MI) – A case report appeared first on CCEM Journal.

We are located in Garo Hills. Garo Hills is part of the State of Meghalaya. It is mainly inhabited by the people of the Garo Tribe. In terms of Medical Care it is one the most backward parts of the North East.

The major challenges are:

• Poor connectivity  and distance( Some areas  are completely in access able during the monsoons)
• Poorly operated Primary Health Centres
• Lack of medical professionals.

With the bulk of medical professionals seeking to be located in towns the major gap in the health care has been in the rural areas.

Need for Critical Care in the Rural:

The major population in any community is rural. The lack of health literacy, distance and transportation, social stigma and belief in traditional medication, patients are very often brought acritically ill. This has created an unpreceded demand for Critical Care Services. With little to no basic facilities at the Primary Health Centres the critically ill patients often succumb or are referred.

Experience of Critical Care in a rural setting:

The need to support the Medical work by providing cost effective and high quality health care in rural Garo Hills has been the primary goal of Garo Hills Adventist Mission Nursing Home. The Nursing Home is located in a small village called Jengjal, West Garo Hills A junction with accessible roads to all parts of Garo Hills.

It has been over 15 months since the Nursing Home has been established and we have been able to see how a basic knowledge in Critical Care can be lifesaving and very rewarding.

The team consists of two Paediatricians, a Gynaecologist, a Dentist supported with 4 nurses. The Nursing Home is a 10 bedded facility. The ER is a 5 bedded set up which has basic facilities eg,Cardiac Monitor, ECG machine and oxygen.

With being the only institution outside the main town providing specialised care in Paediatrics and Obstetrics and Gynaecology, a good number of patients present critically ill.

The most common critically illness cases are Acute Myocardial Infartion, Hypertensive Emergencies, Septic Shock,  Status Asthmaticus, Anaphylactic Shock , foreign body in the ear, Snake Bites, Insect Bites, Renal Colic, croups, Status Epilepticus  and in OBGYN Eclampsia.

It has been our experience that with a basically equipped ER, a standard emergency management protocol and a trained medical team many of the most commonly encountered emergencies can be treated well even at a rural Health care centre.

Author:

Dr. Denyl Avinash Joshua
Medical Director
Garo Hills Adventist Mission Nursing Home
Jengjal, West Garo Hills
Meghalaya

The post Critical Care Medicine in a Rural Setting appeared first on CCEM Journal.

Antimicrobial resistance is a global threat which now a well known matter. Out of which carbapenem resistance is growing which is very alarming. In India it is reported in the range of 12.26 to as high as 26.54%.

Material and Methods:

We performed sensitivity tests using Ezy MIC Strip in 20 consecutive meropenem resistant isolates of Klebsiella, Acinetobactor,Pseudomonas and E. Coli which were grown in standard media and sample taken from urine, sputum, pus, blood and endotracheal tube secretion.

Results and discussion:

In all the 20 samples we tested for Metallobetalactamase presence, 10 are metallobetalactamase positive, 3 are metallobetalactamase negative and remaining 7 are metallobetalactamase non determinate meaning resistance is due to mechanisms other than metallobetalactamases. If you see the MIC values, all are substantially lower in Meropenem plus EDTA than Meropenem alone.

Conclusion:

Clinically if organism is Metallobetalactamase positive,  carbapenem with EDTA can be suggested for clinical use.

References:

1. K. Nair, Pravin. (2013). Prevalence of carbapenem resistant Enterobacteriaceae from a tertiary care hospital in Mumbai, India. Journal of Microbiology and Infectious Diseases. 03. 207-210. 10.5799/ahinjs.02.2013.04.0110.
2. https://ccemjournal.com/emergence-of-carbapenem-resistance/

Author:

Dr. Apurba Kumar Borah
Consultant and HOD, Department of Critical Care and Emergency Medicine
Narayana Superspeciality Hospital
Guwahati, Assam

Dr. Vicky Lahkar
Consultant Microbiologist
Narayana Superspeciality Hospital
Guwahati, Assam

The post In Vitro Sensitivity of Meropenem Vs Meropenem with EDTA appeared first on CCEM Journal.

A 44 year old African American female with chronic dyspnea and dry cough for two years, presented with worsening dyspnea, productive cough, subjective fever and more than 10% weight loss, since last three months. Three months prior to presentation, she was diagnosed with Sarcoidosis based on clinical and radiological findings. She had not received any steroid or immunosuppressive therapy.

On Physical examination, she was found to have low grade fever, mild hypoxia, and occasional crackles in bilateral lung fields. Lab data: WBC 14,700/cmm with 88% neutrophils, Chest X ray showed bilateral perihilar lymphadenopathy and chronic bullous disease of upper lobes with new upper lobe parenchymal infiltrates.

She was placed on respiratory isolation and was started on empiric antibiotics for community acquired pneumonia. Pulmonary was consulted for cystic sarcoidosis and for the evaluation of new infiltrates. AFB smears and HIV antibodies were negative. BAL showed multinucleated giant cells and asperillus fumigatus. She was started on voriconazole for semi-invasive pulmonary aspergillosis. She was subsequently discharged with partial resolution of symptoms.

Semi-invasive aspergillosis, also known as chronic necrotizing aspergillosis progresses over months to years usually affecting upper lobes. It is known to be exclusively seen in patients with chronic lung disease who are immunocompromised due to the use of steroids. Our case raises the question of whether chronic lung disease alone in an otherwise immunocompetent host is a risk factor for the development of semi-invasive aspergillosis.

Author:

• Pinky Bora-Saikia, MD
  Cooper University Hospital, UMDNJ-RWJMS, Camden
• Ashwini Bhat, MD
  Cooper University Hospital, UMDNJ-RWJMS, Camden
• Anuradha L. Mookerjee, MD
  Cooper University Hospital, UMDNJ-RWJMS, Camden

The post Semi-invasive Pulmonary Aspergillosis superimposed on untreated, longstanding Sarcoidosis. appeared first on CCEM Journal.

This is a case of an young patient  with repeated ingestion of Datura and  the management of the patient  with Neostigmine with benzodiazepam .

Case Report:

16 yrs old patient with history of past psychiatric illness on SSRI was admitted in ER with ingestion of Datura Stranmonium . He has past similar history but very mild in nature.

On arrival in ER , patient was very restless and agitated with psychotic behavior. He had high temperature (102.2 degree F). He had tachycardia, dry skin and mucosa and urinary incontinence.  After initial resuscitation patient was electively intubated and put on mechanical ventilation. He was given activated charcoal and started on midazolam infusion. As the poisoning was severe in nature we started him on Neostigmine in fusion at the rate of 0.5 mg/Hour.

The Neostigmine and Midazolam infusions were continued for 24 hrs. His neurological status was assessed. On successful assessment and satisfactory recovery he was gradually weaned off from mechanical ventilator and extubated. One day next he was discharged from ICU to ward.

Discussion:

DATURA STRAMONIUM (DS) is a hallucinogenic plant found in urban as well as rural areas and was used sometimes as a recreational agent for its euphoric effects in low dose.Its toxicity is due to its content Tropane Alkaloids, the contained atropine, L-hyoscyamine and L- Scopolamine which causes anticholinergic syndrome that results in inhibition of central as well as peripheral muscuranic neurotransmission . Typical symptoms of Datura poisoning manifests as confusion, Psychosis, agitation, seizure and coma in severe cases. Other symptoms include dry skin, dry mucosa, flushing, sinus tachycardia, decreased bowel activity, urinary incontinence and respiratory failure. Rhabdomyolysis and fulminant hepatitisare also seen in rare cases. Datura toxicity usually occurs within 60 mins of ingestion and clinical symptoms may persists upto 48 hrs.

Conclusion:

Datura poisoning can sometimes be very fatal if not treated adequately and timely. Specially elective intubation and mechanical ventilation early is very safe for the patients. Use of midazolam and neostigmine infusion is found to be very effective in our case. So we recommend this measures in urgent and effective manners.

The post Datura Poisoning : A Case report appeared first on CCEM Journal.

• To ensure that nutritional requirements of critically ill patients shall be met with ideal calorie and protein density or modifications necessary in particular nutrient composition.
• Critically ill patients who are not able to take oral feed shall be nutritionally supported by giving enteral feed.
• Only commercially available nutritive formulae are used.
• If patient hemodynamically stable then feed start within 24 hours.
• 80% calorie and other nutrients target should be achieved within 24 hours.

 Procedure:

• Enteral Tube nutrition
• Authorization: dietician and doctor
• New Admission
  • Treating consultants based on the clinical and patho-physiological parameters of the patient shall assess and give written order to start enteral feed.
  • Instructions (volume and nutritional requirements) in the patient’s medical record. The ward secretary/ sister in charge shall inform the dietician through the Special Diet Requisition Slip or through phone.
• Process of RT feed
  • Doctor written order
  • Nurses inform to dietician
  • Dietician consult with doctors and calculate calories and decide the method (continuous or bolus) and writes in feed chart and assessment form
  • Nursing staff follow the instruction till further advice
  • Any change in the advice by doctor
  • Nursing inform to dietician/dietician get information through taking rounds
  • Dietician writes in the assessment form about the change
  • Nursing staff follow the instruction till the next advice by doctors

Diet Change:

The treating consultant shall communicate through written instructions for each patient in the medical record for any enteral feed modification (changes in volume and/or nutritional requirements and method of feed).

Periodicity:

Based on the clinical condition of the patient the consultant shall give instructions for changes in the enteral feed plan, which may vary from 1-3 modifications in a 24 hour diet cycle. The same information shall be communicated to the Dietician by the nursing in-charge/allocated sister.

Documentation:

• Progress Note: The specific enteral feed instructions for each patient shall be prescribed by the treating consultant in the patient’s medical record in the progress note.
• Special Diet Requisition Slip: Allocated nurse should write the special diet order mention in progress note and sent it canteen and also provide information to dietician.
• Dietician will write the instruction about RT feed in nutritional assessment form. And she need to update every time after any changes in RT feed and will document in reassessment form.

Nutritional Assessment:

• Authorization: dietician
• New Admission: Concerned floor dietician after receiving the enteral feed instructions in the form of Special Diet Requisition Slip shall carry out the nutritional screening and assessment within 24 hrs of admission on a Nutritional Assessment and Planning Format.
• Diet Change: The concerned floor dietician in accordance with the enteral feed prescription given by the treating consultant shall formulate the feed.
• Modification: The concerned floor dietitian shall do modifications in the current enteral feed formula.
• Periodicity: As and when the message is received.

Documentation:

• New Admission: Nutritional screening shall be filled in Nursing Assessment on admission Form (done soon after admission by the sister in charge), Nutritional screening and assessment shall be filled in Nutritional Assessment and Planning Form (done within 24hours of admission by the allocated floor dietician).
• Diet Change: Initiation of Special Diet Requisition slip/ OR Telephonic
• Modification: Putting up and Reviewing of Nutrition Chart.

Translating prescription into Enteral feed formula:

• Authorization: Dietician shall be authorized to plan the enteral feed formula in consultation with the treating consultant.
• Calculation: The calorie and protein requirements shall be scientifically calculated based on the BMI and physical activity of the patient or RDA (as given by ICMR for under 18) or BEE (as per Harris Benedict’s Equation)
• Formulation for adults:
  • CALORIES
    • Per kg: 25 – 35 kcal/kg IBW
    • Harris-Benedict prediction equation x injury factor
      • Male : BEE = 66.47 + (13.75 x weight in kg) + (5.0 x height in cm) – (6.76 x age in years)
      • Female : BEE = 655.1 + (9.56 x weight in kg) + (1.85 x height in cm) – (4.68 x age in years)
  • PROTEIN
    • Per kg: 1.2 – 2.5 grams/kg in critical illness/injury or for repletion
    • As percent of total kcal: 15 – 25%
  • LIQUID
    • By weight: 25 – 35 ml/kg depending on age, sex, activityb. By calorie intake: 1 ml/kcal
    • Limit in CHF, edema, oliguria, hyponatremia, SIADH
    • Increase if abnormal gastrointestinal, skin or renal fluid losses
    • Consider all sources, intravenous, enteral and oral
  • TIMINGS: 2nd / 3rd hourly
  • SUPPLEMENTS: Only formula feed
• Formulation for Pediatrics:
  • CALORIES
    • Pre operative or post shunt
      • 90-100kcal /kg( ventilated)
      • 120-150kcal/kg(non ventilated)
    • Post operative or post shunt
      • 90-100kcal /kg( ventilated)
      • Actual body weight + activity 1.2+ stress1.5-1.6 (non ventilated)
    • PROTEIN
      • Follow RDA  .
    • LIQUID
      1. 150ml/kg (Premature < 2kgs  )
      2. Neonates  and infants 2-10kgs(0-6months) is 150ml/kg  and for 6-12 month is 120ml/kg
      3. Infant and children 10-20kg is  1000ml +50ml over 10kgs
      4. Children >20kg is  1500ml +20ml over 20kgs
      5. Consider all sources, intravenous, enteral and oral
    • TIMINGS: 2nd/ 3rd hourly/ CONTINOUS
    • SUPPLEMENTS: only formula feed
• Documentation: Enteral feed formula shall be planned on Nutrition Chart Formulation form and it shall be documented in Nutrition Chart. Subsequent planning for next day shall be done on Nutritional Re-assessment & Planning form and if completely the feeds / nutritive values are to be altered a new Nutrition Chart will be put up by the concerned floor dietician.

Therapy Plan:

• Authorization: Only dietician is authorized to fill the therapy plan and response to nutrition is recorded.
• Periodicity: Frequency of updating shall be every day or as per nutritional requirement.

• Documentation: All the updations or modifications are recorded in Nutritional Re-assessment & Planning form by the Dietician.
• Parenteral nutrition: Treating consultant shall prescribe parenteral nutrition formulae and the volume of administration in consultation with the dietician..

Preparation, storage handling and distribution of parenteral feeds shall be the responsibility of the pharmacy. Administration of Parenteral nutrition shall be done by nursing staff. Dietician shall record the calorie and protein intake for 24 hours on Nutritional Re-assessment & Planning form.

RT feed protocol:

• Rt feed can be given bolus or continuous or intermittent as per patients clinical condition decided by dietician or doctor.
• Start feed for patient with contentious feeding by giving plain polymeric formula with RTH. Target1000 Kcal in first 24 hours. Try to archive required nutrients target with in 72 hours  for patients by bolus or contentions or both type of feeding
• In case of bolus feeding initiation RT feed should be start with 50ml and followed by 100ml then 150ml and finally 200ml 2nd hourly which is a full strength of a feed according to the patient condition and tolerance.
  • If patient is not tolerating more than 100ml then only 100ml feed will be continued as per doctor advice.
  • Each time feed is given, tube should be flushed with 30ml of clear water.
  • Residual volume should be checked four hourly and if it is above 300ml then it should be informed to doctors.
  • In case patient is missing feed due to some test and other reason RTH should be given in night time as continuous feed.
  • In case of loose stool, diarrhea and uncontrolled sugar continuous feed should be given.

Author:

Dt. Shabista Nasreen
Head Dietician
Narayana Superspeciality Hospital,
Guwahati, Assam

Dr. Apurba Kumar Borah
Head of the Department, Critical care and Emergency Medicine
Narayana Superspeciality Hospital,
Guwahati, Assam

The post Nutritional Process In Patients On Enteral Or And Parenteral Nutrition In A Tertiery Care Centre In North East India appeared first on CCEM Journal.