Postgraduate medical journal
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Critically ill patients invariably require nutritional intervention. Traditionally, enteral nutrition has not been widely employed in this patient population. This is due in part to the success of present-day parenteral nutrition, and to difficulties encountered with enteral feeding. ⋯ Enterally administered nutritional support can and should be utilised as the preferred route of nourishment for the critically ill. The appropriate choice of access and formula, as well as a rational strategy for implementation, should improve the likelihood of success. This article describes the unique features of critical illness as they pertain to nutritional support, the benefits of enteral nutrition, and the obstacles to success, and offers suggestions which may improve the ability to provide nutrients adequately via the intestinal tract.
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Purtscher's retinopathy presents to the clinician as loss of vision in a patient with a history of a possible precipitating event such as recent major trauma, pancreatitis, childbirth or renal failure. The ophthalmological picture is one of ischaemia at the posterior pole with white patches of oedema and haemorrhages concentrated around the optic disc. ⋯ Complement-mediated aggregates, fat, air, fibrin clots and platelet clumps may all be involved in what is most likely to be a multifactorial process. There is at present no recognised treatment for the condition.
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Metformin is contraindicated in patients with renal failure because of the risk of lactic acidosis. This study assessed the complications of metformin treatment in patients with non-insulin-dependent diabetes mellitis with normal and raised serum creatinine. Subjects using metformin with serum creatinine above the upper reference range (120 mu mol/l) were identified (n = 17) from a hospital diabetes register; those with abnormal liver function, cardiac failure, peripheral vascular disease or recent severe illness were excluded. ⋯ The mean plasma lactate in subjects with serum creatinine 80-120 mu mol/l (2.640 mmol/l (SD 1.434) p < 0.02) was higher than non-diabetic control levels while diabetic subjects with serum creatinine 120-160 mumol/l had a mean of 2.272 mmol/l (SD 0.763) p < 0.05. There was no significant difference between the two groups taking metformin, nor any significant difference in the reporting of gastrointestinal symptoms between the groups on metformin (11.76% vs 12.5%). Plasma lactic acid levels are higher in diabetic subjects taking metformin compared with healthy volunteers but, within the diabetic groups, the small elevation of serum creatinine was not associated with higher plasma lactate levels.
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In the light of the recent Calman Report and the Royal College of Anaesthetists document 'Specialist training in anaesthesia, supervision and assessment', there is currently much debate concerning the future of anaesthesia training in the UK. We present a description of anaesthesia training in the US for discussion and comparison. ⋯ It is highly structured, but retains a capacity for specialisation. It may offer ideas for the future direction of training in the UK.
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A previously fit 48-year-old man was admitted with an acute respiratory failure due to mycoplasma pneumonia that was confirmed by raised mycoplasma titre on complement fixation test. It was also associated with disseminated intravascular coagulopathy. The patient made a full recovery but required intermittent positive pressure ventilation.