Parenteral hyperalimentation

Nasogastrointestinal intraluminal tube stenting in the prevention of recurrent small bowel obstruction

Nasogastrointestinal intraluminal tube stenting using a Dennis tube (Sherwood Medical St Louis, Missouri, USA) was performed on 25 patients. Two intubations were for midgut volvulus, 13 for small intestinal obstruction after extensive adhesolysis, and 10 as an adjunct to the operative management of enterocutaneous fistulae following extensive adhesolysis, resection and anastomosis. No patient developed recurrent small bowel obstruction for periods up to three years after operation. Use of an intraluminal tube stent in preventing recurrent small bowel obstruction due to adhesions is safe and effective when used on appropriately selected patients. Its effectiveness should be more widely recognized.

Rubber sump drainage of enterocutaneous fistulae

Effective sump drainage of high enterocutaneous fistulae, together with alimentary rest and total parenteral nutrition, is now an integral part of the modern management of patients with this condition. The low tissue reactivity of the plastic and polymer materials currently used in most drainage tubes appears however, to be counterproductive to the establishment of a discrete fistula track and control of the fistula. A case is made for the use of red rubber sump drains for enterocutaneous fistulae. The greater tissue reactivity of rubber is reviewed and confirmed by animal experimentation. A method of rubber sump drainage of enterocutaneous fistulae developed during the management of 83 such fistulae is described.

Insulin loss in parenteral nutrition systems

This study investigated insulin adsorptive loss occurring in various infusion systems used in regimens of parenteral nutrition. The results suggested early and considerable insulin loss in dextrose infusion solutions with doses of insulin used clinically. Maximum percentage loss occurred within 30 seconds following administration of insulin to infusion bottles of 5% and 50% dextrose. Mean insulin loss over eight hours amounted to 47·6%± 2·0 s.e.m. in 5% dextrose and 34 · 8% ± 1· 5 s.e.m. in 50% dextrose. The combination of infusion bottle and infusion set further increased the mean insulin loss in 50% dextrose to 43 ·6%± 1·7 s.e.m.

Percentage insulin loss in bottles of 5% dextrose decreased with increasing insulin concentration, however, insulin loss in 50% dextrose was unaffected by varying insulin concentration. The addition of human serum albumin (0·05% w/v) to 50% dextrose lessened insulin loss to a small but significant extent and mean insulin loss in solutions of Aminofusin 600 was only 14·0% ± 1·6 s.e.m. over 30 minutes.

With a regimen of parenteral nutrition in any one patient, it would seem logical where possible to add insulin to one type of parenteral nutrition solution only, so that the variability of insulin adsorptive loss seen with different solutions may be minimized.

Intravenous hyperalimentation in the management of the critically ill patient, with special reference to abdominal fistulae

The present paper described the technique of intravenous hyperalimentation applied to a group of 100 surgical patients. A specially prepared diet supplying a high amount of calories, using hypertonic glucose and supplying nitrogen, using polypeptides or aminoacid solutions, was infused into the superior vena cava. The inhibition of digestive secretions, during the period of hyperalimentation, was used in the management of 19 patients with intestinal and pancreatic fistulae. The general conclusion reached after wide clinical experience was that by supplying energy and nitrogen to a patient in a severe catabolic state, a significant and sometimes dramatic capacity could be developed which allowed him to overcome difficult conditions and even initiated a reversal of the metabolic balance in the direction of anabolism. The regimen should be adopted in the preoperative preparation of debilitated patients; in hypercatabolic states (post-trauma, post-surgery or burns); in gastrointestinal, granulomatous or infectious diseases; in acute pancreatitis; in digestive fistulae; in oncological conditions, and so on. The metabolic and infective complications can be pregressively decreased and eventually prevented by proper handling and strict metabolic monitoring. The use of this hyperalimentation was extremely encouraging, and on many occasions we had the impression that it was life saving.

Subphrenic abscess: a study of 241 patients at the Royal Prince Edward Hospital, 1950-73

A series of 241 patients with subphrenic abscess was analysed to seek reasons for the continuing mortality. Aspects of pathology, clinical presentation, special investigations and management were affected by therapy with broad spectrum antibiotics to make diagnosis more difficult, particularly in relation to left subphrenic abscesses. When transperitoneal exploration and drainage were employed, high morbidity and mortality resulted. Satisfactory results followed extraserous drainage. The introduction of parenteral hyperalimentation promised control fistulas associated with abscesses, a situation hitherto associated with a poor prognosis.