Laparoscopic treatment of pyloric atresia in a newborn

Introduction. Pyloric atresia is one of the rarest surgical diseases in newborns. Laparotomy is the most common modality for correcting this abnormality. In modern scientific literature, there is only one report on the endosurgical treatment of pyloric atresia. The case of laparoscopic correction of gastric outlet atresia presented in this study is one more reference to the successful care of this condition.Material and methods. The presented clinical case is a newborn boy in whom a prenatal ultrasound examination at the 31st week of gestation revealed polyhydramnios and an enlarged stomach. The baby’s birth weight was 2660 grams. In the first hours of life, the child showed symptoms of high intestinal obstruction in the form of gastric content vomiting. Postnatal ultrasound and X-ray examination confirmed the diagnosis of pyloric atresia. During laparoscopy, performed on the 2nd day of life, the morphological type of anomaly was examined, and the type I atresia of membranous form was established. A laparoscopic membranectomy with Heineke–Mikulicz pyloroplasty was performed. In the final part of this research, early and late outcomes of the performed surgical treatment were analyzed.Results. The surgery lasted for 70 min. Postoperative period was uneventful. Enteral nutrition started on day 3 after the surgery. A complete enteral diet was possible on day 7. The newborn patient was discharged from the hospital on the 9th postoperative day. Histological examination confirmed the pyloric atresia of membranous type. During 12-month follow-up, no complications associated with the surgical procedure were seen.Conclusion. The described case of laparoscopic treatment of type I pyloric atresia in a newborn expands laparoscopy application in pediatric practice.

Indicadores de qualidade da terapia nutricional enteral são ferramentas úteis para o monitoramento em pacientes com câncer avançado em cuidados paliativos?

Introduction: Enteral nutritional therapy (ENT) in patients with advanced cancer in palliative care should be directed towards a better quality of life, being important its monitoring so that the patient has access to the best that the therapy can offer. The objective of this study was to apply the quality indicators of ENT in patients with advanced cancer in palliative care. Methods: Descriptive, observational study with a quantitative approach. Seven ENT quality indicators proposed by the International Life Sciences Institute in Brazil were applied and the reasons for the suspension or interruption of the enteral diet during hospitalization were quantified. Results: 51 patients admitted from May to November 2019 participated in the study. The frequencies of inadvertent exit of enteral nutrition tube (0.02%), the days of adequate administration of the prescribed volume versus infused volume (92.6%) and diarrhea (2%) are within the goal used. The administration of protein (25.5%) and energy (57.4%), the frequency of episodes of abdominal distension (33.3%) and constipation (86.3%) were inadequate. The diet was interrupted or suspended mainly due to the occurrence of vomiting, end-of-life care or tube obstruction. Conclusion: The use of quality indicators of nutritional therapy proved to be viable in this group of patients. Some inadequacies found in this population may be associated with the change in the objective of nutritional therapy in patients with shorter life expectancy. Adaptations based on the prognosis may be necessary, in addition to the application of new indicators, or adjustments to the proposed goals.

Nutrição enteral precoce e desfechos clínicos em pacientes de terapia intensiva

Introduction: Early nutritional support is a therapeutic strategy in critically ill patients, however, it has been shown to be controversial in relation to clinical outcomes. The aim of the study was to investigate the effects of early enteral nutritional therapy (ENT) and the initial caloric-protein supply on the clinical outcomes of patients in Intensive Care Units (ICU) of a hospital in Southwest Bahia. Methods: Prospective cohort study approved by the ethics committee. Information was collected on nutritional screening, anthropometric assessment, estimated nutritional needs and nutritional goals. The time of introduction of NET was classified as early, when started in the first 48 hours of admission and late. The volume and characteristics of the enteral diet were monitored daily, as well as the length of stay in the ICU and mechanical ventilation and mortality. Patients were followed up until discharge from the ICU or death. To test the association between the outcomes of mechanical ventilation time and ICU stay and nutritional variables, linear regression was used, while, for mortality, logistic regression. Results: 88 patients were included, of which 96.6% had nutritional risk at admission, determined by the severity of the condition. Early NET was received by 67 patients, with a mean of 39 ± 11.69 hours to onset and significant variation in relation to late NET (77.76 ± 32.11 hours), with no association with outcomes. The caloric and protein averages received in the first three days of NET were significantly higher in the early NET group (p = 0.000), which were associated with longer ICU stays and mechanical ventilation, even with a high frequency of protein inadequacy. No late ENT patient presented protein adequacy until the third day. Conclusion: Early NET was not associated with the clinical outcomes of critically ill patients, however, the greater energy supply increased the ICU stay and mechanical ventilation times.

An Immune-modulating Diet Maintains Food Intake during Cancer Chemotherapy

An immune-modulating diet (IMD), an enteral diet enriched with immunonutrition and whey-hydrolyzed peptides, has been shown to bring an improvement of prognosis by suppressing inflammation after surgery or under stress. In this study, we have experimentally and clinically examined the effect of the IMD in cancer chemotherapy. In experiments using colorectal cancer cell-transplanted mice, the mice fed with the IMD in combination with anti-cancer agent showed significantly to maintain their body weight excluding tumor, and to reduce plasma interleukin-6 (IL-6) levels compared with the control group. Furthermore, normal mice fed with the IMD elevated the level of plasma ghrelin, in particular acyl ghrelin. An clinical trial for a patient with malignant lymphoma revealed that the acyl/desacyl ghrelin ratio and total calorie intake was increased when the patient was supplemented with the IMD in conjunction with chemotherapy. These results suggested that the supplementation of the IMD during cancer chemotherapy might enable to maintain the food intake of the patients through elevating their acyl ghrelin levels

Nutrição enteral em sistema fechado para pediatria: escolha com base na disponibilidade no comércio brasileiro e na rotulagem

Introduction: The enteral diet (ED) for pediatric nutrition should ensure the appropriate nutritional intake for the child and/or adolescent. Therefore, during the selection of ED, in addition to the patient’s needs, the characteristics and nutritional composition of the patients should be taken into account. Thus, the objective was to identify and characterize the diets for pediatric enteral nutrition, in a closed system, currently available in the Brazilian market, in order to assist nutritionists and doctors in prescription. Methods: The descriptive and documental research consisted in the identification of the diets for pediatric enteral nutrition, in a closed system, currently available in the Brazilian market and characterization of the diets, based on labeling data. The data of interest for the development of this study were collected in catalogs and official websites of the manufacturers and suppliers and books of enteral nutrition and nutrition in pediatrics. Results: In Brazil, nine pediatric enteral nutrition diets are available in a closed system, marketed by three manufacturers. It was found that the diets for pediatric enteral nutrition can be indicated for a wide age range, from one to 10 years and patients in different pathophysiological states. There is little variation in the levels and sources of macronutrients. Four enteral diets present fibers in their composition and 5 are hypotonic. Conclusions: The Brazilian market has a limited number of diets for pediatric enteral nutrition in a closed system, which makes prescribing a challenge for nutritionists and doctors. It can not be said that a particular pediatric enteral diet in closed system is better than another, each one has specific characteristics. This makes it necessary for to carefully evaluate the professionals adequacy of the diet to the patient’s clinical situation and individuality.

Food for Thought: Dietary Intervention in a Rare Cause of Severe Ventilatory Failure

Plastic bronchitis is a rare condition characterised by endobronchial cast formation. We report the case of a 53-year-old women who deteriorated following an elective bronchoscopy procedure. She developed refractory ventilatory failure and required repeated bronchoscopy, which identified thick tenacious casts as the cause of her airway compromise. She did not respond to conventional therapies including endoscopic clearance, mucolytic therapy and nebulised tissue plasminogen activator (TPA). Total parenteral nutrition and a fat-free enteral diet were instituted while the patient was on extracorporeal membrane oxygenation (ECMO), which led to substantial improvement in her condition and demonstrated the importance of dietary strategies in this case.

Impact of Glycemic Variability and Hypoglycemia on the Mortality and Length of Hospital Stay among Elderly Patients in Brazil

Background: Glycemic variability (GV) is an alternative diabetes-related parameter that has been associated with mortality and longer hospitalization periods. There is no ideal method for calculating GV. In this study, we used standard deviation and coefficient of variation due to their suitability for this sample and ease of use in daily clinical practice. Objective: This study aimed to investigate the association between GV, hypoglycemia, and the 90-day mortality and length of hospital stay (LOS) among non-critically ill hospitalized elderly patients. Methods: The medical records of 2,237 elderly patients admitted to the Zilda Arns Elderly Hospital over a 2.5-year period were reviewed. Hypoglycemia was defined as a glucose level <70 mg/dL (hypoglycemia alert value) and represented by the proportion of days in which the patient presented with this condition relative to the LOS. The Charlson comorbidity index was used to evaluate prognosis. Data were analyzed using multiple linear and logistic multivariate regression analyses. Results: Adjusted analysis of 687 patients (305 men [44.4%] and 382 women [55.6%], mean age of 77.86±9.25 years) revealed that GV was associated with a longer LOS (p=0.048). Mortality was associated with hypoglycemia (p=0.005) and mean patient-day blood glucose level (p=0.036). Variables such as age (p<0.001), Charlson score (p<0.001), enteral diet (p<0.001), and corticosteroid use (p=0.007) were also independently associated with 90-day mortality. Conclusion: Increased GV during hospitalization is independently associated with a longer LOS and hypoglycemia in non-critically ill elderly patients, while the mean patient-day blood glucose is associated with increased mortality.

Indicadores de variabilidade glicêmica e mortalidade em pacientes críticos com terapia nutricional

Introduction: Glycemic variability (GV) has been associated with mortality in critically ill patients. Several methods have been used to measure it, but no guideline has so far proposed a gold standard. The aim of this study was to associate different GV measurement methods with mortality in patients in an intensive care unit (ICU) under nutrition therapy (NT). Methods: Retrospective longitudinal study conducted between April and September 2018, in which 82 patients were enrolled in intensive care, with more than 48 hours of hospitalization and using NT. Demographic data, clinical data and all blood glucose values measured during hospitalization were collected. The GV was evaluated through three indicators: standard deviation (SD), coefficient of variation (CV) and glycemic mean (MGL). Statistical analysis was performed using Whitney and Pearson Chi-square tests, univariate and multiple logistic regression, and odds ratio. The analyzes were processed and evaluated using the Statistical Data Analysis software version 12.0. Results: 11,676 blood glucose levels were measured. Most of the sample received enteral diet. Mortality was 42.7%. A total of 36.58% of the patients had a previous diagnosis of diabetes mellitus (DM) and these presented higher values for all evaluated parameters of VG compared to non-diabetics. CV, SD and MGL values were higher among the patients who died. Univariate logistic regression analysis showed that the variables CV, SD and MGL were significantly associated with mortality. However, based on the multivariate logistic regression model, only PD maintained a relationship with mortality. Conclusion: The SD is an indicator of GV is independently associated with increased mortality in a cohort of heterogeneous patients on TN in the ICU.

CUIDADOS NA ADMINISTRAÇÃO DE MEDICAMENTOS POR SONDA ENTERAL

The objective of this study was to discuss the use of drugs in patients submitted to enteral nutritional therapy. The study had a cross-sectional, observational design of a quantitative nature, in which 30 patients of both sexes, older than 18 years, were admitted to the emergency room of a public hospital in a city in the interior of São Paulo, who were using Nutritional Therapy Enteral, with drugs prescribed by the tube. In the results it was verified that of the total of drugs that were used, 42.85% presented some type of interaction with the nutrients of the diet, being 87.5% of negative interactions; 12.5% of positive interactions and 7.14% did not find any type of interaction. In conclusion, it was observed that there are numerous situations that cancause interactions between the prescribed drugs and the enteral diet, leading to nutritional and drug deficiencies, reducing the effectiveness of both, contributing to depletion of the patient's nutritional state and hindering its recovery.