Question: Is a disease-specific enteral formulation needed for critically ill patients with liver disease? Hepatic Failure Question: Should energy and protein requirements be determined similarly in critically ill patients with hepatic failure as in those without hepatic failure? Based on expert consensus, we suggest a dry weight or usual weight be used instead of actual weight in predictive equations to determine energy and protein in patients with cirrhosis and hepatic failure, due to complications of ascites, intravascular volume depletion, edema, portal hypertension, and hypoalbuminemia. We suggest that nutrition regimens avoid restricting protein in patients with liver failure, using the same recommendations as for other critically ill patients (see section C4). Rationale: Heightened nutrition risk and deterioration of nutrition status are highly prevalent among patients with chronic liver disease and are nearly universal among patients awaiting liver transplantation. The degree of nutrition risk is directly correlated with the severity of liver dysfunction. The portal hypertension and impaired protein synthesis associated with liver failure contribute to ascites and edema, rendering weight-based tools of nutrition assessment inaccurate and unreliable. Usual or dry weights are often difficult to determine due to the chronicity of the disease. The primary etiology of malnutrition in hepatic disease is poor oral intake from multiple factors, including alterations in taste, early satiety, autonomic dysfunction with resultant gastroparesis, slow small bowel motility, and slow orocecal transit. Malnutrition in patients with cirrhosis contributes to increased morbidity and mortality. Soft/low-fat diet vs clear-liquid diet in mild acute pancreatitis, hospital length of stay. Acute Pancreatitis Question: Does disease severity in acute pancreatitis influence decisions to provide specialized nutrition therapy? Based on expert consensus, we suggest that the initial nutrition assessment in acute pancreatitis evaluate disease severity to direct nutrition therapy. Since disease severity may change quickly, we suggest frequent reassessment of feeding tolerance and need for specialized nutrition therapy. Rationale: Mild pancreatitis is defined by the absence of organ failure and local complications. Moderately severe acute pancreatitis is defined by transient organ failure lasting <48 hours and local complications. Organ failure is defined by shock (systolic blood pressure <90 mm Hg), pulmonary insufficiency (Pao2/Fio2 300), or renal failure (serum creatinine 1. Severe acute pancreatitis is defined by persistent organ failure lasting >48 hours from admission. Question: Do patients with mild acute pancreatitis need specialized nutrition therapy? We suggest not providing specialized nutrition therapy to patients with mild acute pancreatitis, instead advancing to an oral diet as tolerated. If an unexpected complication develops or there is failure to advance to oral diet within 7 days, then specialized nutrition therapy should be considered. Although promising, the data are currently insufficient to recommend placing a patient with severe acute pancreatitis on an immune-enhancing formulation at this time. Question: Should patients with severe acute pancreatitis be fed into the stomach or small bowel? References 47, 53, 61, 345, 347Â350, 353 References 47, 53, 345, 346, 348, 350, 353 McClave et al 187 Figure 12. In the absence of a commercial product, a recommendation for a specific dose and type of organism cannot be made at this time. Lower energy provision is suggested early in the resuscitative phase, with liberalization of energy delivery as the patient enters into the rehabilitation phase. Question: Should immune-modulation formulas be used routinely to improve outcomes in a patient with severe trauma? While several lines of evidence support use in trauma settings theoretically, documentation of outcome M. Surgical Subsets Trauma Question: Does the nutrition therapy approach for the trauma patient differ from that for other critically ill patients? We suggest that, similar to other critically ill patients, early enteral feeding with a high protein polymeric diet be initiated in the immediate posttrauma period (within 24Â48 hours of injury) once the patient is hemodynamically stable. The metabolic response to trauma is associated with dramatic changes in metabolism, with utilization of lean body tissue to serve as gluconeogenic substrates and to support immune and repair functions.
Citrulline is able to move outside the mitochondria, thereby transporting waste products of respiration to the cytoplasm where they can be processed further and ultimately excreted from the body. Over time, the high levels of ammonia will affect the brain, due to the toxicity of the waste product on the neurons. One might postulate that a metabolic defect would render an individual unable to survive without modern medical interventions. Many infants who died in early childhood prior to the advent of sensitive diagnostic testing may have succumbed to a potentially treatable metabolic disease. It is easy to see that there is a natural selection against individuals with metabolic diseases, especially those who have a decrease in survival or basic life functioning. It is, therefore, not surprising that many of the metabolic diseases are inherited in an autosomal recessive, X-linked recessive (males only), or sporadic (new mutation) pattern (1). This also holds true for the lipidoses (disorders in lipid metabolism leading to the accumulation of lipoid material within cells). Presenting signs and symptoms include vomiting, lethargy, poor activity, poor feeding, decreased mental status, and even coma. These disorders usually present in the first few days to weeks of life as the ammonia waste product accumulates quickly, leading to serum ammonia levels which are described as "sky-high" (>1000 umol/L). The initial clinical presenting signs and symptoms (other than hyperammonemia) more commonly signal a serious infection of the newborn. A group of metabolic disorders related to the urea cycle defects is the organic acidemias. Symptoms include lethargy, poor feeding, vomiting, and seizures, which eventually lead to coma and cerebral edema. Laboratory evaluation yields hypoglycemia, hyperammonemia (to a lesser degree than in urea cycle defects), acidosis, and ketosis. The enzyme deficiency leads to build-up of phenylalanine that is toxic in high levels to brain growth and nerve myelination. With a defective enzyme, the individual is unable to produce proper levels of tyrosine which results in poor pigmentation of skin and hair (1,5). In galactosemia, there is an increased likelihood of sepsis from gram negative organisms that may cause death in the neonatal period (1,4,5). In an infant who has signs and symptoms consistent with a metabolic disorder, there are certain diagnostic steps that can help delineate what type of metabolic disorder could exist. With metabolic disorders, one must always ask if there is a family history of early infant death or disability, developmental delay, mental retardation, or seizures. Thus, some investigation for neonatal infection risk factors should be conducted. In addition to the sepsis workup, metabolic screening laboratories should include a glucose level, electrolytes, an arterial blood gas, ammonia level, lactic acid level, urinary ketones, and liver function tests. Once the screening laboratories are available, one can systematically eliminate possible diagnoses until there are only a few possibilities left. Then, a few specific diagnostic tests can be performed to hopefully, identify the type of metabolic disorder that is present. Urea cycle defects have extremely elevated ammonia levels, sometimes in excess of 2000 ug/dL. Infants with elevated ammonia levels in the presence of hypoglycemia have a reasonable likelihood of having an organic acidemia. Hypoglycemia without hyperammonemia can signal a carbohydrate metabolism defect. Persistent, severe, metabolic acidosis with absence of urine organic acids will signal primary lactic acidosis. If the metabolic acidosis is due to a primary lactic acidosis, a lactate/pyruvate ratio may be helpful to further narrow the differential diagnosis (4). Although it may be possible to determine the general class of metabolic defect, it is often not possible to determine the exact enzyme which is defective or lacking. The primary drawback is the 3-4 day turnaround time from receipt of the sample to the results being available.
On rare occasion, the technology designates a wrong answer as the "correct" answer on a quiz question. Be certain to indicate the course, the quiz number, and the first few words of the question in addition to your explanation as to why your selected answer is a better than the "correct" answer. This approach encourages students to become co-creators of their learning experience, at least at a minimal level. It does, in fact, allow the instructor to correct errors that might otherwise distract or annoy other students in the 1 the first author is grateful to the late John Broida for suggesting this strategy. P a g e 122 class and to do so before the impact of the errors becomes unmanageable or disruptive. Implicitly, it also gives students permission to make (and hopefully correct) their own mistakes. Finally, it creates opportunities for faculty to interact with individual students, a topic to which we will return. For example, course requirements can include graded discussion threads and graded peer feedback on course artifacts. It is important to operationally define "substantive" in this context so students know their posts need to include something more than "good job" or "I agree. Such rubrics can also make assigning points to (even large numbers) of discussion threads relatively painless (even if time consuming) for instructors or teaching assistants. Similarly, we frequently require students to provide peer feedback on course artifacts. Regardless of the length or complexity of the writing assignment, students can be required to post their artifact on the discussion board and subsequently provide peer review or feedback to a specified number of peers on the same assignment. We frequently ask students to provide such feedback on drafts of complex assignments. That way students receive feedback from the instructor as well as from their peers that they can incorporate into their final draft regardless of whether the assignment is a book review, wiki entry, letter to the editor, lab report, etc. It may be useful to point out that students may receive contradictory feedback, in this context, and can be empowered to consider the alternatives and make whatever editorial decision they think best serves their audience and the purpose of the assignment. Although graded discussion threads and required peer review encourage student-student interaction regarding course content, some students seek less formal interactions with their peers as a way to enhance their social networks among other non-academic goals (Lewis, Dikkers, & Whiteside, 2017; Whiteside, Dikkers, & Lewis, 2017). For example, we often encourage students to post a brief introduction or bio (and to respond to some of their classmates posts) during the first week of class. Even without assigning a point value to such a post, in our experience, most students appear to do so with pleasure. We often encourage students to take note of others who share their interests or background or who posted something of particular interest so that they can use the email function in Blackboard to further their interaction. The discussion board in our classes often includes a forum with the following instructions. If you have a question, need some assistance, or have experience or expertise to offer, post a note on the Help wanted. For example, if you are willing to help others make connections to people in your network, have technological expertise to share, or are skilled in the kind of research required for this course, you can let others know of your willingness to assist through this forum. Students have used this forum to resolve minor technical problems, announce local events. Because these discussion threads are visible to all students in the class, it also allows the instructor to answer a question once rather than repeatedly to any number of individual students. After all, there is often only one instructor and there are usually many students. Regardless, there are a variety of ways instructors can make their virtual presence known in asynchronous online classes even if there are few, if any, opportunities to meet faceto-face or in real time (Whiteside, Dikkers & Swan, 2017). These include, but are certainly not limited to , weekly announcements, instructor commentaries, and participation monitoring. We use weekly announcements in much the same way many faculty use the first few minutes of a face-to-face lecture. Announcements can also remain on the Blackboard announcement page for the duration of the week (or for whatever period an instructor deems appropriate). They can also be written well in advance, deployed on a schedule, and edited for reuse in subsequent semesters. In fact, we usually draft a weekly announcement for each week of the semester while designing the course and edit or update each message as it is made available to students. Not unlike the introduction to a lecture in a face-to-face class, these messages can include a wide range of information.
Other studies have shown that the media can encourage sedentary behaviors, such as television watching, that may adversely affect energy balance (Gortmaker et al. Media can be used to convey consumer information and public health messages, such as those regarding youth smoking, and seat belt and child car seat use. Social marketing programs that have used the media, either as focused efforts or as part of multi-component campaigns to promote physical activity or healthy diet in adults, have produced mixed results, often because discerning their impact is a challenge. In some cultures this knowledge may encourage women to "eat down" in late pregnancy in order to avoid a difficult birth (King, 2000). Acculturation, the process in which members of one cultural group adopt the beliefs and behaviors of another, is often associated with adoption of unhealthy behaviors, including food choices. A population-based study of 462 mothers in California found that in the three months before pregnancy, foreign-born Latinas had the lowest contribution of fat to total energy intake and the highest dietary intake of carbohydrate, cholesterol, fiber, grain products, protein foods, folate, vitamin C, iron, and zinc, compared to the dietary intake of white non-Latinas and U. Other researchers have also documented increased risk for adverse birth outcomes, including preterm birth and low birth weight, among U. Several intervention studies have been conducted using nutrition advice alone (Orstead et al. Of the 1,643 women who recalled weight gain advice, 14 percent reported being advised to gain less than the recommended levels, and 22 percent were advised to gain more. Provider advice to gain below the recommended levels was associated with actual weight gain below the recommendations (an adjusted odds ratio of 3. Mean birth weight, however, decreased and low birth weight rates increased with increasing altitude. There is some evidence linking environmental contaminants such as organophosphate and organochlorine compounds to fetal growth, but the evidence is inconsistent (Dar et al. Several studies have documented the impact of disasters on pregnancy outcomes such as preterm birth (Weissman et al. A study of urban retail food markets and birth weight outcomes in upstate New York found pregnant women who lived in proximity to urban retail corner markets without fresh produce, dairy, and other healthy foods had significantly more low birth weight infants compared to women who had access to supermarkets where healthy foods were available. The social spaces scale was also associated with decreased odds of living greater than three miles from a supermarket. Negative weight gain attitudes were most common among heavier adolescents, depressed adolescents, and adolescents who did not perceive their families as supportive. The youngest adolescents as well as somewhat older adolescents who conceive soon after menarche may still be growing themselves (Scholl and Hediger, 1993). Even girls who become pregnant for a second time during adolescence may still be growing. This was not true among adolescents who were still growing during a second pregnancy; their infants were significantly lighter at birth than those who were not growing themselves. The possibility of a competition for nutrients between the still-growing adolescent gravida and her fetus has been advanced as an argument for recommending relatively higher gains for at least some pregnant adolescents. What has been found instead is that still-growing adolescents are not mobilizing their fat gain during pregnancy to enhance fetal growth but, rather, are supporting the continued development of their own fat stores (Scholl et al. However, information on these subjects is more limited for pregnancy among adolescents, particularly younger adolescents, than it is for adult women. Gestational Weight Gain in Older Women Increased maternal age is significantly associated with risk for adverse pregnancy outcomes, including stillbirth (Fretts, 2005; Reddy et al. In addition to poor outcomes, pregnancy in older women is also associated with increased risk for pregnancy complications. In addition, obesity was significantly greater in the older compared to the younger women. They found that black women were significantly more likely than white women to gain less than 15 pounds, but less likely than white women to gain more than 34 pounds. Several studies have identified a relationship between food insecurity, defined as "whenever the availability of nutritionally adequate and safe food or the ability to acquire acceptable foods in socially acceptable ways is limited or uncertain" and overweight/obesity (Anderson, 1990). These studies have shown a higher prevalence of overweight and obesity among women living in food insecure households compared to women living in food secure households (Frongillo et al. The mechanisms mediating this association are not well understood, but reports in the literature addressing eating patterns support the idea that food deprivation can result in overeating (Olson and Strawderman, 2008). Polivy (1996) found that food restriction or deprivation, whether voluntary or involuntary, results in a variety of changes including the preoccupation with food and eating. It has also been suggested that food-insecure households tend to purchase calorie-dense foods that are often high in fats and added sugars as an adaptative response to food insecurity (Drewnowski and Darmon, 2005). More recently, Jones and Frongillo (2007) found food insecurity without hunger to be associated with risk for overweight/obesity, but not with subsequent weight gain in women of all racial/ethnic groups.
This means that an infant requiring a higher glucose concentration needs a central line. Ketones are normally generated in hypoglycemic states because the body breaks down fat to acetyl CoA and other ketone bodies, in an effort to generate more substrate for the Krebs cycle. Page - 100 If the patient is stable, the blood sugar is steady at 50 mg/dl or above, and a more serious condition is not suspected, the frequency of blood glucose measurements can be reduced to every 4 to 6 hours. The intravenous glucose infusion may be weaned after the glucose has been stable and in the normal range for 12-24 hours (1). Enteral feedings may be started concurrently if the infant is otherwise stable and fluid overload is not a concern. True/False: the level of hypoglycemia resulting in serious sequelae is well defined by scientific studies. Which of the following infants are at risk for hypoglycemia and should have a screening blood sugar performed in the term nursery? Apgar scores were 7 (-1 tone, -2 color) and 9 (-1 color) at 1 and 5 minutes, respectively. She then has a second seizure, initially noted to start in the right arm which then becomes generalized. The clinical manifestations of seizures in newborns differ significantly from that seen in older children and adults as the human neonatal brain is still in the process of organization and development. Subtle seizures are often difficult to recognize, they occur more frequently in premature infants, and they are not always correlated with electroencephalographic seizure activity. Lastly, myoclonic seizures are composed of rapid, flexion twitching or jerking movements. Asphyxial injury may occur in utero as a result of decreased uteroplacental perfusion, for example in abruptio placenta, cord compression, preeclampsia, or chorioamnionitis. Postnatally, conditions such as persistent pulmonary hypertension of the newborn, cyanotic congenital heart disease, sepsis, and meningitis can also result in hypoxic-ischemic brain injury. However, the timing of onset is not a reliable indicator of the timing of the neurologic injury (4). Seizures due to intracranial hemorrhage may also be associated with hypoxic-ischemic or traumatic injury since these events are frequently associated with each other. Onset of seizures due to subarachnoid hemorrhage or subdural hemorrhage is usually the second or third day of life, while those due to germinal matrix-intraventricular hemorrhage present after the third day (2). Congenital infections with viruses (cytomegalovirus, rubella, herpes, and others) or toxoplasmosis can cause severe encephalopathic disease. Seizures also often occur in neonates with acute intracranial bacterial infections, most commonly Escherichia coli and group B streptococcal meningitis. Metabolic disturbances such as hypoglycemia, hypocalcemia, and hypomagnesemia are associated with neonatal seizures. Newborn infants who are premature and infants of diabetic mothers (large for gestational age, or small for gestational age) are most at risk for hypoglycemia. Those infants who are of low birth weight, born to diabetic mothers, or who have suffered hypoxic-ischemic injury are also at risk for hypocalcemia. Other metabolic abnormalities associated with seizures include local anesthetic intoxication, hyponatremia, and inborn errors of metabolism (2,5). Treatment of neonatal seizures should focus on the primary etiology as well as direct seizure control. Phenobarbital is often used as the first line anticonvulsant, followed by phenytoin and lorazepam. Infants with a normal background activity are less likely to have neurological sequelae as Page - 102 opposed to those with moderate to severe abnormalities such as burst-suppression pattern, voltage suppression, and electrocerebral silence (2). Does the onset of neonatal seizures correlate with the timing of fetal neurologic injury? She is centrally pink with persistent grunting, shallow respirations, and lethargy. The convention in the past has often been to evaluate and empirically treat all neonates felt to be at significant risk, especially as relates to maternal factors and the receipt of maternal antibiotics in labor. The approach in this section of neonatal sepsis will be to: 1) incorporate the evolutionary changes in management which are based on more recent evidence; 2) to emphasize the lack of a gold standard underlying the variations in practice. These are necessary and basic to understanding the problem of neonatal sepsis and perinatal infections.
However, children with difficult to reduce hernias or a history of incarceration in the past are at high risk for future incarceration and strangulation and should be managed more urgently. If, however, a child presents with an incarcerated inguinal hernia and symptoms of intestinal obstruction or shock, a pediatric surgeon must be consulted emergently while resuscitation begins with intravenous fluids and nasogastric tube decompression of the stomach (5). This has a spherical shape and the child is often asymptomatic with the exception of the inguinal mass. In the case of an incarcerated hernia, careful inspection of the incarcerated bowel is done to assess viability. After inspection and reduction, a high ligation of the processus vaginalis is performed (1,4). If a uterus is not palpable beneath the Page - 381 symphysis pubis in the midline, a pelvic ultrasound examination should be done to evaluate for normal female anatomy. There is controversy surrounding the topic of contralateral surgical exploration at the time of herniorrhaphy. Studies have shown that development of a contralateral inguinal hernia after unilateral herniorrhaphy occurs with an incidence of 12-30% (>10% since the contralateral hernia often develops later). Bilateral surgical exploration should also be strongly considered in children less than 24 months of age with left-sided inguinal hernias. This technique allows for visualization of the contralateral side during repair of the affected side. Other significant risk factors for development of an inguinal hernia include presence of a ventriculoperitoneal shunt or peritoneal dialysis catheter. Other conditions associated with an increased incidence of inguinal hernias include congenital dislocation of the hip, ascites, congenital abdominal wall defects, meconium peritonitis, connective tissue disorders (Ehlers-Danlos syndrome), mucopolysaccharidosis (Hunter-Hurler syndrome), ambiguous genitalia, hypospadias/epispadias, cryptorchid testes, and cystic fibrosis. However, if the hydrocele persists beyond this time frame, if it is large and tense, or if the hydrocele is communicating, it is unlikely to resolve spontaneously and can be difficult to distinguish from a hernia. However, there can be complications of surgery including damage to intestine, testis and vas deferens or to ovary and fallopian tube. More commonly, a recurrent swelling is due to reaccumulation within the tunica vaginalis and/or enlargement of retained tunica vaginalis tissue due to edema. Each testis descends through the inguinal canal into the scrotum within the processus vaginalis. A scrotal hydrocele, or simple hydrocele, is a type of non-communicating hydrocele. Which of the following is not a risk factor for development of an inguinal hernia? This was followed by vomiting her lunch and a bowel movement, which did not relieve the pain. The pain has moved to the right lower quadrant and is increased by walking and coughing. Abdomen: Bowel sounds hypoactive with right lower quadrant tenderness and guarding. The Pathologist Reginald Fitz of Boston first described the condition of appendicitis in 1886 and in 1887, the Philadelphia surgeon T. Morton performed the first successful removal of an appendix which had been perforated. S (subjective or symptoms): We find the subjective symptom of abdominal pain to be epigastric or mid-abdominal in location associated with anorexia and vomiting in most cases. At this point with the knowledge that abdominal pain can also be caused by genitourinary, respiratory, gynecological, lymphatic and neurological diseases, application of deductive reasoning should lead the diagnostician to ask whether or not the child has a respiratory infection with cough, sore throat or chest pain; whether or not there is radiation around the right flank or dysuria and groin pain indicating a urological cause; or in a girl, whether or not the pain radiates to the anterior right thigh indicating pain of ovarian origin. So we see that children with appendiceal inflammation causing peritoneal irritation tend to lie motionless and often say that the pain is aggravated by walking. The next step in physical diagnosis and slightly more intrusive is auscultation with a stethoscope. As appendiceal inflammation progresses, the protective mechanism of the bowel causes it to become less active and bowel sounds are diminished until the belly becomes quiet with frank peritonitis.
In 2005, adolescents (< 20 years old) were more likely to gain excessive weight during pregnancy than women 35 years of age and older. In 2005, weight gain of < 15 pounds was more common among black and Hispanic than among white women (Figure 2-5). Within each racial or ethnic group, the proportion of women with low gains increased with advancing age. The total number of women who gained > 40 pounds was 456,678 in 1990, 588,253 in 2000, and 656,363 in 2005. Birth certificate data may yield more useful statistics for weight gain surveillance in the near future. For obese women, average weight gains were well above the 15-pound recommended minimum. The majority of overweight women had weight gains greater than the recommended range (Figure 2-7). By 2002-2003, only about one-quarter of overweight women gained within the recommended range. For obese women, there was a modest rise in the prevalence of excessive weight gain from 1993-1994 to 2002-2003. By the end of the observation period, only one-third of obese women gained within the recommended range. The percentage of underweight women gaining within the recommended range rose slightly from nearly 36 percent in 1997 to just over 40 percent by 2007, while the percentage gaining below the recommended range declined from 41 percent to 32 percent. In all racial/ethnic groups, the rates of high weight gains increased, low weight gains decreased, and recommended weight gains varied little (Figure 2-9). Non-Hispanic black women and Hispanic women had similar rates of low weight gain and were more likely than non-Hispanic white women to gain less than the recommended levels. Importantly, none of the data highlighted here provide information on pattern of weight gain. Postpartum weight status for a population can be represented in a variety of ways, including absolute weight change, percentage who retain a specific amount of weight over the prepregnancy weight. Furthermore, it is important to assess postpartum weight retention according to both prepregnancy body size. Unlike pregnancy, when maternal weight is monitored and routinely recorded in the clinical record, data on maternal postpartum weights are not widely available, particularly for times later in the year after birth. More than 40 percent of women who gained excessively retained > 20 pounds (Figure 2-11). Respondents were more likely to be non-Hispanic white and to have higher education and lower parity than the general U. Importantly, obese women who gained within or less than the recommended range maintained a postpartum weight below their prepregnancy weight. However, postpartum weight retention remains a problem for a large proportion of mothers, even at one year after birth. These data also show that obese women who gained within or below the recommended ranges experienced a net loss in weight from their prepregnancy weight. However, for those who gained below their recommended range, the more time that passed after the birth, the more they experienced a net increase in weight and approached their prepregnancy weight. A greater proportion of infants in 2005 were born to nonwhite mothers, with the largest increase in births from Hispanic mothers. Childbearing by unmarried mothers sharply increased in this 15-year period to a record high of 36. More mothers attained high levels of education; in 2005, more than one-quarter of mothers had 16 years or more of education. The proportion of births for mothers 35 years and older also increased substantially in this interval. Although the teenage birth rate had been steadily declining since 1991, preliminary data from 2006 suggest that the overall birth rate for teenagers rose 3 percent to 41. Teenage mothers 10-14 years of age were the only group that did not experience an increase in birth rate during this time.
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